In any critical surgical case, expert medical and dietetic management is just as necessary as expert surgical skill and, on the average, there is the same likelihood that the surgical specialist can satisfactorily discharge the former duties as that the internist can perform a difficult, technical operation.

Healthy persons, sustaining a fracture, a non-septic wound or other accident, not involving a high degree of shock and not affecting the viscera, or undergoing a corrective, non-emergent operation with absence of the two factors just mentioned, require no particular dietetic management, but allowance should be made for change of habits with regard to exercise etc., and there is frequently a demand for laxative diet.

A general anaesthetic should not be given when the stomach contains food or any considerable quantity of liquid. Even if no anaesthetic is given, the pain and shock of operation will probably reflexly inhibit digestion, so that it is better to operate with the stomach empty, although coffee or even an alcoholic may be employed as a stimulant. Under such circumstances, provided that there is no inherent cardiac weakness, alcohol is usually satisfactory, since the main necessity is for psychic stimulation. Indeed, if sufficient alcohol is given, genuine anaesthesia results, there being no essential difference between the effect of ethyl oxid (ether) inhaled, or absorbed from the rectum, and of ethyl hydroxid (alcohol) taken by mouth.

In preparing for anaesthesia, allowance must be made for abnormally slow gastric motility which may, indeed, be due to the reflex inhibition of dread and pain. Thus, while theoretically a patient to be operated on at eleven, might take coffee and roll, or bread and milk, or beef broth and crackers, or some similar light meal, at seven, it is unwise to run any chance of asphyxia from vomiting during anaesthesia. In non-emergent operations, it is far better to give the last meal in the evening and to operate rather early in the morning, before hunger and thirst are felt. In emergency cases in which the stomach contains food or liquid, emesis should be produced, the tube being usually inadequate to remove solid food.

In the after care of the class of surgical cases under discussion, no special dietary is necessary but the following points should be remembered:

1. The patient - excepting for the ambulant treatment of fractures, dislocations and comparatively slight wounds, not interfering with locomotion - needs only the ration of a sedentary or recumbent individual.

2. Pulpy laxative fruits and vegetables are usually indicated to combat the tendency to constipation.

3. Processes of repair theoretically require a relative excess of protein, though not more than is contained in the ordinary, unrestricted diet, and meat and blood extracts are indicated if there has been much haemorrhage; fresh vegetable foods for their content of lime, after fractures; gelatin if there is a tendency to renewed haemorrhage; alcohol to prevent delirium tremens if the patient has been accustomed to considerable use of such beverages; per contra, in conditions involving nervous shock, as head injuries and falls, an excess of carbohydrates might perhaps better be avoided, though the danger of the glycosuria to which such injuries predispose is not very obvious; in fractures, especially, if lipuria appears, and in the obese, fats should be reduced to the minimum.

4. Owing to the general reduction of vitality, all foods should be as simple and digestible as possible, without suggesting to the patient that he is on a sick man's diet.

A second group of surgical cases includes those in which the vigor of the patient has been undermined, either by the pathologic process for which the operation is undertaken - for example pyosalpinx, pyothorax, tuberculous peritonitis - or by surgical shock incident to the injury or to the operation itself, as in cranial operations, resection of a kidney, operations involving much haemorrhage and delay - but in which there is no marked local digestive lesion and, particularly, no traumatic or operative solution of continuity of the alimentary canal.

In such cases, feeding by mouth can usually be resumed as soon as the nausea due to the anaesthetic has passed off, or, at most, after a delay of 24 hours. On the one hand, sepsis is favored by lack of nourishment, on,the other by saprophytosis in the intestine. Even if the patient is obese or gouty, this is no time for starvation treatment. Intestinal atony and spasm, either of which occasionally follows operation, seems to be prevented to some degree by the presence of alimentary contents. The most appropriate diet is that for early convalescence from fevers - milk, eggs, singly or variously combined, toasted bread and crackers, beef juice and extracts, jellies etc., using alcohol, tea and coffee, according to special indications and peptonizing or making use of rectal or hypodermatic nutrition if necessary.

The third group of surgical cases consists of those in which the primary lesion, pathologic or traumatic, or the secondary, essential or accidental surgical lesion, or both, involve the alimentary canal itself. For practical purposes, we must also include in this group, various biliary, hepatic, pancreatic and intraperitoneal operations, in which the diet has a very direct and marked influence on the immediate result.

As a general rule, cases of this nature should not be fed by mouth, or through a fistula established at the time of the operation, for at least 24 hours. While a considerable degree of plastic union may be expected at the expiration of this interval, it is wise not to test its strength for at least two or three days or, in the case of extensive resections, anastomoses etc., for a week, unless the indication for nutrition is urgent, as in gastrostomy deferred until starvation is imminent, after oesophageal closure.