CHAPTER XVI
DIETETIC TREATMENT BEFORE AND AFTER OPERATION
PREOPERATIVE FEEDING
The dietetic treatment which is essential before and after operations is deserving of attention here, since it constitutes one of the points so frequently overlooked or slighted. As a rule the treatment depends (1) upon the character of the disease for which surgical intervention is necessary, and (2) upon the general health and physical condition of the patient in question.
~Preparatory Treatment.~--In many cases it is found to be advisable to build up the patient before subjecting her to the shock of an operation, and the more serious the operation the more necessary this "building-up" process.
The character of the disease also has much to do with the preliminary diet. In certain pathological conditions involving the gastro-intestinal tract, for example, the patient comes to the surgeon after medical treatment has failed to give relief and surgical intervention is necessary to save life. The body is found to be in a condition bordering on starvation, anemic and exhausted from insufficient nourishment. The functions of the blood-making organs have become out of gear, as it were, and the blood consequently is deficient in one or more of its essential elements. For such patients it is wise to attempt to reenforce and strengthen their bodies before operation, that they may have more endurance to withstand the shock which is more or less unavoidable.
~Adjusting the Diet.~--In any case where preliminary diet is prescribed the condition for which the operation is necessary determines the nature of the diet; for example, if the operation is to be upon the kidney, the diet beforehand would naturally be in the nature of a nephritic one to save the diseased organ unnecessary work. If the stomach or intestinal tract required surgical care, the diet would necessarily be formulated to meet the particular needs of the organ in question, an analysis of the stomach content furnishing the keynote of the diet. In any case the food must be simple in character and well prepared. All food in any way liable to bring about indigestion should be studiously avoided.
~Habits.~--The habits of the patient must be regulated so that she may not "overdo"; at the same time, gentle exercise may be the very thing needed to give an impetus to the appetite and thus assist in the adding of strength for the approaching ordeal. Many patients respond readily to a change of air and scene and frequent small meals instead of a few large ones,--a lunch in the mid-morning and mid-afternoon hours, consisting of a glass of milk and a cracker or malted milk chocolate or reenforced fruit juices. A cup of warm milk before retiring induces the much-needed sleep, hence is advisable under the circumstances.
~The Bowels.~--The bowels must be kept open. Coarse bread such as that made from bran or graham flour is advisable. Prunes and figs cooked with senna leaves are likewise simple laxatives which are both palatable and effective. For stubborn cases of constipation it is often found that a teaspoonful of a conserve made with a third of a pound each of raisins, prunes, and figs ground fine, with an ounce of senna leaves added, taken at bedtime and before breakfast, will overcome the condition and make the patient more comfortable and the general health better.
~Preliminary Light Diet.~--The day before the operation the diet must be light; the intestinal tract must not be filled with a food mass which is difficult to get rid of. On the morning of the operation the patient is given no food if the operation is to be performed at an early hour, otherwise a cup of tea, coffee, weak cocoa, or broth with a cracker is given. Some physicians give a glass of milk at this time, while others do not. It is the physician who must decide the question if there is any doubt about it. The stomach must be empty before administering the anesthetic.
In certain emergency operations when it has been impossible to prepare the patient ahead, the difficulties attending the administering of the ether are sometimes greatly increased. The cleansing of the stomach and intestinal tract oftentimes eliminates or materially decreases the nausea and vomiting which so often forms one of the most dreaded sequences of the operation. For this reason many surgeons require the patient to be given lavage before leaving the operating room.
~Total Abstinence.~--No food is given for twenty-four hours following the operation (1) on account of the nausea and vomiting which so often follows the giving of an anesthetic--ether particularly--and (2) because the entire organism is better for a complete rest.
~Routine Treatment.~--The routine treatment in uncomplicated cases is rest, then water, very hot or iced, or carbonated, or vichy in spoonful doses, then albumen water, broth, etc., then milk, buttermilk, koumiss, etc., after which the semi-solids, etc., until a normal diet is reached. After a week or more the character of the operation certainly determines the dietetic treatment. To quote Dr. Thomas S. Brown,[106] "To give the same diet after pyloroplasty, gastro-enterostomy, gall bladder operation, or gastric resection as we would after operations for fracture of the thigh or cancer of the breast shows a basic ignorance of the pathologic physiology of the former group of cases." "We should remember that hyperacidity remains long after the underlying cause has been removed and it is tempting providence, to say the least, to ply these patients with tomato soup, salad dressing, and coarse food in the early stages of their convalescence."
~Character of Diet.~--It must be kept in mind that the character of the diet is of vital importance, especially in the after-treatment of operations upon the stomach. In gastro-enterostomy, for example, the food mass passes from the stomach directly into the upper part of the small intestine through the new opening. Thus the semi-liquid food highly acid in character comes in direct contact with the delicate intestinal walls which are accustomed, not to the acid, but to a neutral or alkaline medium.
~Adjusting Diet to Disease.~--Thus it is demonstrated that unless care is used in selecting the diet this portion of the intestinal tract will be injured; hence the nurse must understand which foods are liable to stimulate an excess flow of acid in the stomach and avoid them. She must also keep in mind that the foods given must be in a semi-liquid or very finely divided condition, since the mechanical efforts made by the musculature of the gastric organ act as a direct stimulant to the secretory cells of that organ.
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Much of the responsibility thus rests upon the nurse whose business it is to administer the diet. The efforts of the best surgeon in the world may be entirely overcome by a careless, thoughtless, or ignorant nurse.
~Rectal Feeding.~--In some cases it is found necessary to nourish the patient more than is possible by mouth. This is especially so with emaciated and very weak patients and for those who have undergone operations upon the mouth or throat and in some of the above-mentioned stomach cases when the passage of any food over the newly-operated-upon surfaces is inadvisable. In these cases rectal feeding is resorted to and from two to three nutrient enemas[107] alternated with saline enemas are given daily.
Under ordinary conditions when the patient has not been operated upon for gastro-intestinal disorders, gall bladder or kidney diseases, the dietetic regime is as follows:
~Postoperative Feeding.~--First day: starvation, a little hot or cold water or carbonated water may be given if there is no nausea or vomiting. If nausea or vomiting persists, a few spoonfuls of champagne or clam broth or juice will often check or relieve it entirely. Fluids alone must be given during the first forty-eight hours after the operation. When stimulation is necessary, albumen water or coffee containing a spoonful of brandy[108] will be found useful. When nausea entirely disappears, well-skimmed broth milk, clam or oyster broth, buttermilk, koumiss, malted milk, may be given. A gradual return to the normal diet is made, adding soft toast, soft-cooked eggs, junket, ice cream, meat, wine, or fruit jellies before solid food is introduced into the dietary.
~After-care in Feeding.~--Care must be observed to prevent indigestion after almost any operation, but especially after abdominal operations there is a great tendency to form gas, hence anything which in any way increases the tendency may bring about a condition of extreme discomfort and even acute pain to the patient. For this reason it is unwise to follow too closely the desires of the patient as to the food to be eaten; for example, corned beef and cabbage may be the thing of all others desired by the patient, but it would be the height of folly to risk such a meal until all danger of digestional disturbances is at an end. It is wiser to avoid such disturbances than to trust to relieving them after they occur. The digestion of even a perfectly normal individual is at a disadvantage when that individual is deprived of outdoor exercise. How much more so will it be when the entire organism is taxed by the ordeal through which it has just passed. Convalescence is never hastened by imprudent eating, and a condition as bad as the original may be brought on by lack of care on the part of the one whose business it is to feed the patient.
CONDITIONS REQUIRING SPECIAL DIETS
~Diet After Appendicitis.~--After a simple operation for appendicitis the same regime is carried out as in stomach and intestinal operations: fluids on the second day, soft diet on the third, and solid food of the simplest character and prepared in the simplest way may be given on the fifth and sixth days. When, however, the operation has been of a more serious character, for example, when there was pus formation or a gangrenous appendix, the feeding by mouth must not be instituted for five days or more, nutrient enemas being used instead. Patients have been known to die from exhaustion after operations upon the stomach and intestines, not on account of the operation but on account of the lack of reserve power and endurance to carry them through the ordeal without a sustaining diet to overcome it. Under the circumstances Dr. F. Ehrlich[109] advises the following routine method: "So soon as the nausea from the anesthetic has worn off the patient gets tea, red wine, and gruel; on the day after the operation he is given sweetbreads in bouillon even if it nauseates him; if the nausea is persistent, his stomach is washed. On the second day finely chopped cooked squab, chicken, or veal, is added; on the third day, beef, potato puree and cakes; on the fourth, chopped (raw) ham, soft zwieback, and soft-boiled eggs. On the fifth, white bread and spinach. After the seventh day the meat is not chopped, and the patient returns gradually to normal diet. The bowels are regulated by oil enemas."
~Diet After Operation upon Gall Bladder or Liver.~--The dietetic treatment in these cases is like that of any other abdominal operation except for the character of the food. Fats are not well handled by the body of such individuals and should be eliminated as far as possible from the diet. Broths must be skimmed carefully to remove fat, and milk when given should be skimmed or given in the form of buttermilk or koumiss.
~Diet After Operations upon the Kidneys.~--The diet administered after operations upon these organs is logically one in which those foods which are entirely dependent upon the kidneys for their elimination are restricted. In a former chapter the fate of the foods in metabolism was explained; the protein foods were seen to be the ones leaving the body chiefly by way of the kidneys and for this reason in the diet after operations upon these organs, as well as in that administered in disturbances affecting their functioning powers, this food constituent, the protein of meat in particular, must necessarily be restricted. The upsetting of the nitrogen equilibrium is for so short a period after kidney operations that this feature need not be considered here. The diet under the circumstances is essentially the same as that given during acute attacks of nephritis.
SUMMARY
~Factors Affecting Diet~ before and after operations must be considered under two heads, namely, the character of the disease for which the operation is considered necessary and the general physical condition of the patient at the time.
~Emaciation and Anemia~ are often encountered in patients having certain gastro-intestinal disturbances for which surgical intervention was found to be necessary. At times a preliminary up-building treatment is required before it is considered wise to submit the patient to the shock of so serious an operation.
~Adjusting the Diet~ according to the character of the disease for which the operation is to be performed is most important. It is not always possible to build up the body beforehand, but in many cases it is necessary to make the effort. At times the reenforcing of the diet and a certain amount of gentle massage will enable the patient to pass through the trying ordeal more comfortably than would otherwise be possible.
~Selecting the Diet~ to conform to the character of the disease is as important a factor in the recovery of the patient as food itself. This selection is left largely to the nurse, consequently it is necessary that she should understand just which foods are indicated or contraindicated under the circumstances, and adjust the diet after the abstinence period accordingly. For example, the diet fulfilling all the needs of a patient who has just undergone an operation for a broken leg might be highly injurious for a patient just operated upon for some disturbance of the liver or kidneys. The diet given after must be essentially like that given just before the operation, in order that the affected organ may have an opportunity to heal and return to its normal functioning power.
~Gastro-intestinal Disturbances~ must be avoided, both before and after the operation. In the preliminary treatment, when every effort is being made to increase the strength and endurance of the patient, such disturbances do away with any gain brought about by judicious dieting. After the operation, attacks of indigestion not only cause pain and discomfort as a result of the gas formation, but may cause symptoms far-reaching and even dangerous in their effects. The diet, then, must be composed of the simplest food and prepared in the most careful manner, the amount of food given at a time must be small--it is wiser to feed the patient oftener than to run the risk of indigestion by giving more than can be readily handled by the already taxed digestive apparatus.
~The Bowels~ must be kept open in the majority of cases. Peristalsis is stimulated by the giving of water and fruit beverages as soon as it is advisable to give anything by mouth.
~Reenforcing the Diet~ is at times necessary in order that the patient's strength may be kept up. In such cases lactose, eggs and some of the predigested casein or beef preparations are found to be valuable.
~Before the Operation~ the patient must be made ready to take the anesthetic. This is done by preventing an accumulation of food in the intestinal tract. The day before the operation, then, it is necessary to limit the diet materially by giving food in small amounts. The light diets prescribed in acute conditions are as a rule suitable, unless otherwise indicated.
~The Day of the Operation~ a cup of tea, coffee, or broth may usually be given, with a cracker, unless the operation is to be performed early in the morning, in which case the patient is given no food at all. Some physicians allow a glass of milk on the day of the operation, but this is left entirely to the physician in charge.
~After Operation~ a period of total abstinence from both food and water is necessary in order not to increase or induce nausea and vomiting. As soon as these symptoms subside, unless otherwise indicated, a certain amount of hot, cold, or carbonated water may be given. After this, albumen water may form the first nutrient administered. Milk, broth and fruit beverages follow the giving of albumen water, after which the semi-solids, such as soft eggs, gelatin and milk soups, constitute the convalescent diet.
~The Character of the Diet~ after the operation depends wholly upon the nature of the disease for which the operation was deemed necessary.
~Diet After Gastro-enterostomy~ must be adjusted in order not to increase the acid content of the gastric organ, otherwise the delicate mucous linings of the intestines would be subjected to direct contact with materials which are irritating in character, owing to the fact that the mass passes through the new opening and has thus been deprived of the neutralizing agents found in the upper part of the intestinal tract. Under the circumstances milk, albumen water and fine cereal gruels are the best foods from which to formulate the diet after the necessary period of abstinence and fluid diet.
~After Appendicitis~, as a rule, no food is given for five days in cases where there has been a pus formation and the appendix gangrenous. Otherwise the routine treatment diet is given--water, then albumen water, followed by broth, milk and fruit beverages, fine cereal gruels, etc.
~After Liver and Gall bladder Operations~ the character of the food must be considered. The fats are not well handled in such conditions and must be avoided as far as possible. Broths must be well skimmed and the milk fat free. Buttermilk and koumiss are probably the most suitable forms in which to give milk in these cases.
~After Kidney Operations~ the work of elimination through kidney must be limited as far as possible in such cases. While it is impossible to rest the organ entirely, the giving of a proper diet under the circumstances will do much toward relieving the strain placed upon it. The protein foods, with the exception of milk, must be excluded from the diet. The regime practiced in acute nephritis gives the most satisfactory results.
PROBLEMS
(a) Write a diet order for patient operated upon for gastric ulcer.
(b) Formulate diet to be used after a gall bladder operation.
(c) Outline diet used after operation upon the kidney.
FOOTNOTES:
[106] "Some Gastro-intestinal Notes," "The Medical Clinics of North America," Vol. I, No. 1, pp. 192-193, by Thomas R. Brown, Johns Hopkins Hospital.
[107] See Formulas for Nutrient Enemas, p. 145.
[108] See Albumen Water with Brandy, p. 141.
[109] "Diet in Health and Disease," p. 555, by Friedenwald and Ruhraeh.