Surgery, with Special Reference to Podiatry Part 30

The firmness with which the bandage is put on is, of course, chiefly for the purpose of gaining the good effects of compression on the structures beneath, but besides, it contributes very much in making the bandage remain in its position when applied. Encircle the limb with it in a loose, careless manner, and it will fall down almost immediately the patient begins to walk about. Tight bandaging is extremely well borne if performed in a complete and methodical way, beginning at the lowest portion of the foot around the first joints of the toes and ending just below the knee.

The proper application of the bandage is of such great importance, especially in the treatment of varicose ulcers of the leg, that it should, when possible, always be done by the doctor himself. It is difficult for the most skilled layman to put a bandage on his own leg.

The real practical difficulty lies with those patients who live at a distance from the doctor and who can only visit him once a week or at ten day intervals. These must be taught to dress and bandage the limb, and generally some friend or relative will learn to superintend the details.

The length of time which elapses before the bandage and dressings are removed and reapplied must necessarily be determined by the circ.u.mstances of each case. When the ulcer is very extensive and the discharge proportionately great, it may be advisable to dress the leg every day at the beginning of the treatment. Generally speaking, an ulcer of the leg is disturbed too often. To take off a dressing and put on another, even though done with the greatest care, interrupts the healing process and the natural steps to cure. Let the dressing remain on until some uneasiness points to the propriety of taking it off, for the purpose of allowing the escape of the discharge. Delay the removal of the dressings as long as possible without carrying the forbearance too far. Avoid extremes of waiting too long or of meddling too soon. Taking the average case, an interval of three days may in general be safely permitted.

+Spiral Bandage of the Great Toe.+ In applying this bandage, the initial extremity of the roller is secured by two or three turns around the ankle and the bandage is carried obliquely across the dorsum of the foot to the base of the toe to be covered, and next to its tip, by oblique turns; a circular turn is then made and the toe is covered by ascending spiral or spiral reverse turns until its base is reached, from which point the bandage is carried obliquely across the dorsum of the foot and finished by one or two circular turns around the ankle.

The end of the bandage may be secured by a pin or may be split into two tails and secured by tying.

+Spica Bandage of Great Toe.+ This bandage is applied by placing the initial extremity of the roller upon the ankle and fixing it by two circular turns; the roller is then carried obliquely over the dorsal surface of the foot to the distal extremity of the great toe; a circular turn is next made and the bandage is carried upward over the back of the great toe to the ankle, around which a circular turn should be made; ascending figure of eight turns are then made around the great toe and the ankle, each turn overlapping the previous one, two-thirds, and each figure of eight turn alternating with a circular turn around the ankle. These turns are repeated until the great toe is completely covered with spica turns and the bandage is completed by circular turns around the ankle.

+French Bandage of the Foot.+ In applying this bandage the initial extremity of the roller should be fixed on the leg just above the ankle and secured by two circular turns around the leg; the bandage should be carried obliquely across the dorsum of the foot, to the metatarsophalangeal articulation, at which point a circular turn should be made around the foot; the roller should then be carried up to the foot, covering it with two or three spiral reverse turns; after this a figure of eight turn should be made around the ankle and instep; this should be repeated once to cover the foot, with the exception of the heel, and the bandage continued up the leg with spiral reverse turns.

+Spica Bandage of the Foot.+ In applying this bandage, the initial extremity of the roller should be fixed just above the ankle and secured by two circular turns; the bandage should then be carried obliquely over the dorsum of the foot to the metatarsophalangeal articulation; a circular turn around the foot should be made at this point and the bandage continued upward over the metatarsus by making two or three spiral reverse turns; it should then be carried parallel with the inner or the outer margin of the sole of the foot, according as it is applied to the right or left foot, directly across the posterior surface of the heel, and from this point it should be conducted around the outer border of the toe and over the dorsum, crossing the original turn in the median line of the foot, thus completing the first spica turn. These spica turns should be repeated, gradually ascending, by allowing each turn to cover three-fourths of the preceding one, until the foot is covered, with the exception of the posterior portion of the sole of the heel; the turns should cross one another in the medium line of the foot and should be kept parallel throughout their course.

+Bandages for the Foot and Leg.+ Whenever possible the patient should be kept in bed, or, at least, in the rec.u.mbent position with the leg elevated, but when circ.u.mstances do not permit of this the veins can be supported in various ways. Elastic stockings are excellent but expensive, and not durable. Bandages of rubber cloth, or woven bandages rendered elastic by the character of the mesh, or Martin's plain rubber bandage may be employed. The last named is put on smoothly but not too tightly, for in walking the leg swells, so that a uniform pressure is established. As the rubber prevents evaporation it acts like a wet compress, stimulating the granulations, but very often producing eczema around the ulcer. The rubber bandage should be washed carefully at night with soap and cold water and must be kept clean. In one patient a firm elastic stocking of vulcanized rubber will give the greatest ease and comfort, while in another the resulting irritation will prove unbearable. As regards the flannel bandage it has already been described at some length.

The essential feature of ambulatory treatment is a good dressing to prevent congestion, and Unna's paste is ideal for this purpose. The paste necessary for the bandage is prepared as follows: first dissolve four parts of the best gelatin in ten parts of water by means of a hot water bath. While the fluid is hot add ten parts of glycerine and four parts of powdered white oxide of zinc; stir briskly until the mixture is cold. Another formula for the paste, and the one recommended, consists of the following: white gelatin, 2-1/2 ounces; water, 8 ounces; zinc oxide, 2-1/2 ounces, and glycerine, 4 ounces; prepared as above. The paste should always be melted before use by placing the receptacle in a hot water bath or in an ordinary copper sterilizer, such as that employed for boiling instruments. A small tin can be used, and a piece of paste about four inches square is cut into fine pieces and put in the can. This is placed in the sterilizer, into which is poured water to a depth of about two inches, so that the can is but slightly immersed. No top should be placed on the can. An ordinary stove or gas range can be used for heating purposes. A very important fact to remember is that no water is to be put into the can with the paste.

The leg is next cleansed, and after the paste has been thoroughly melted it is applied from the base of the toes to the knee, as hot as the patient can comfortably tolerate it, by means of an ordinary small paint-brush. Then a layer of gauze bandage (two to three inches in width, according to the limb) is applied, then a layer of paste, and in this manner two or three thicknesses of bandage are used, depending on the case. In thin people, it is necessary to use only one or two layers of bandage, whereas in stout persons several layers may be required. After the last application of the paste, some non-absorbent cotton is spread on the bandage, giving it the so-called "moleskin"

plaster finish. Another way of finishing the dressing is to dust some ordinary talc.u.m powder on the last layer of the paste, giving the bandage the appearance of a plaster-of-Paris dressing. If there is an ulcer, a window can be cut out, thus providing for the drainage of the secretions. The length of time this dressing should be left on depends on a number of conditions, especially the amount of secretion, and whether the patient has to remain on his feet very much. Ordinarily, the bandage can remain on for one week, but indications may be such that it need not be removed sooner than the tenth day, and in some instances it can be kept on for three or four weeks. To remove it, an ordinary bandage-scissors is used to cut the dressing, and it peels off without disturbing any of the granulations on the ulcer.

+PROMOTION OF NEW EPITHELIAL GROWTH AND CICATRIZATION+

The value of nitrate of silver and red wash as stimulants of the healing process has already been mentioned. They are also of value in producing cicatrization and in promoting the covering of new epithelium over the ulcer or wound. If the solid stick of nitrate of silver be applied very lightly to the edges just inside the pale bluish line of advancing epithelium, so as to produce a white film on the surface, this slight cauterization will be found to aid in strengthening and cornifying the new, delicate and previously invisible epithelial cells and in preventing them from being washed away by the discharge from the ulcer. The solid stick of nitrate of silver is also of benefit in destroying the exuberant granulations which project above the surface of the surrounding skin; often, by piercing these flabby granulations in several places with the solid stick held perpendicular to the surface, cicatrization is hastened.

After the granulations are level with the surrounding skin the covering of the ulcer or wound with new epithelium is hastened by the application of some smooth surface along which the epithelium can spread. For this purpose zinc oxide plaster or some thin rubber may be used.

In some old chronic cases, healing is prevented by the fact that the base of the ulcer cannot contract owing to its being bound down by fibrous scar tissue. This binding down of the base and edges of the ulcer also tends to cut off the blood supply, and therefore in this additional manner healing is hindered. For the relief of this condition a number of procedures have been devised. Mattress sutures, introduced through the normal skin beyond the edges of the ulcer and pa.s.sing beneath it, out through the skin on the other side, is one method. By tightening these sutures, over a b.u.t.ton or metal plate, the ulcer can be lifted from the underlying tissues. Another method, called "starring of the ulcer," consists in a series of radiating incisions through the base and edges of the ulcer, the part from which the incisions radiate corresponding with its centre. In this and in the following operations, in order to obtain a favorable result, it is necessary that the incisions pa.s.s completely through the cicatrical tissue which forms the base and edges of the ulcer into normal tissue.

"Cross-hatching" of the base of the ulcer by means of a series of incisions at right angles to one another, and at a distance of about one-half inch apart, is often of value in aiding the healing of a chronic ulcer, the continued existence of which and failure to heal having been due to its thickened, adherent base and edges.

Circ.u.mcision of a chronic ulcer consists in making a circular incision around it through the normal skin. A modification of this method consists in making a series of overlapping, short, curved incisions surrounding the ulcer, instead of a single circular incision. In these last two methods it is necessary that the incisions be made through normal skin, and that the wounds be made to gape, if necessary, by packing them with gauze.

When the ulcer or wound is of considerable size, it is often impossible to secure healing even by these methods. It may for a time appear as if it were going to heal, and a pale blue line of newly formed epithelium may spread out from the edges, but instead of the epithelium continuing its progress, at a subsequent dressing it will be found to have disappeared. In these cases, as well as in those in which the size of the ulcer would necessitate a long delay for a cure or in which the subsequent contraction of the scar would produce deformity, skin grafting, skin transplantation, or some form of flap operation is indicated.

+SKIN GRAFTING TO OBTAIN A SOUND SCAR+

A very important object in the treatment of all ulcers is to obtain a sound scar. In ulcers affecting the lower extremity in elderly people, the scar resulting from spontaneous healing is weak and readily breaks down if the patient does much standing or walking. The patient is therefore frequently obliged to give up work in order to get the ulcer re-healed, or must be content to employ means which merely prevent its extension and relieve some of the discomfort. When the best possible scar is desired, and when it is important to avoid marked contraction, it is necessary to adopt some method of skin-grafting.

There are three plans by which rapid healing of an ulcer may be brought about: Reverdin's epidermis grafting; Thiersch's skin grafting, and the use of the whole thickness of the skin.

+Reverdin's Method.+ In this procedure small thin portions of the superficial layer of the skin are snipped off with a curved scissors.

Pieces about the size of a hemp seed are planted on the surface of the granulations at short distances from one another. Epidermic growth occurs from each of these little points, and the result is that numerous small islands of epithelium form over the surface of the ulcer. If the grafts be close enough together and the conditions be favorable to healing, these islands soon coalesce and thus rapid cicatrization is obtained. The grafts should not be too far apart, because they appear to have only a limited power of reproduction.

+With a view to obtaining a sounder scar+, thicker and more extensive portions of the skin must be taken and the grafts must be applied close together. There are two ways of doing this: either by using the whole thickness of the skin or by employing Thiersch's method, in which about half the thickness of the skin is shaved off.

The procedure where the whole thickness of the skin is employed need not be described, partly because the results are not satisfactory and partly because all the conditions for which it was introduced are better fulfilled by Thiersch's method.

Skin grafts may be taken either from the patient himself or from another individual. When the patient is much debilitated, the cutaneous epithelium shares in the general malnutrition and under these circ.u.mstances a graft from a healthy subject might succeed better than one taken from the patient.

+Thiersch's Method.+ In employing this method the skin which is to be used for the grafting must first be shaved and disinfected in the usual manner, as has been previously described. The presence of hairs on the grafts seems to interfere materially with their union.

+Preparation of the Ulcer.+ _Preliminary._ It is of no use to graft a sore which is actually ulcerating; it must be brought into a healthy condition, and healing must have commenced before transplantation is likely to be successful. The best criterion that healing is taking place is the presence, at the edges, of the dry line which indicates recently formed epithelium. Some surgeons wait for a considerably longer time before grafting in order to get a firm layer of granulations, but experience shows that it may be safely resorted to as soon as healing begins around the edge. A second essential is that the ulcer shall be clean. If the discharges be septic, the graft, which is, after all, merely a piece of dying tissue, will become impregnated with decomposing pus and may rapidly become loosened, die, and undergo decomposition. The methods of rendering the ulcer aseptic have already been described.

_Operative._ The following is the method of procedure: after the patient has been placed under an anesthetic, the granulations over the whole surface of the ulcer are forcibly scrubbed off with a firm nail-brush, or are evenly sc.r.a.ped away, taking care, however, to remove only the soft layer of granulations and not to go through the deeper one of newly formed fibrous tissue into the fat. A surface is thus left which is smooth, highly vascular, and firm, and which consists of the deeper layers of granulation tissue that have already become organized into fibrous tissue. In cases of ulcer of the leg it is also advisable to remove those portions of the edge which have already become covered with new epithelium. If the transplantation be limited to the parts actually unhealed, the result is disappointing as a rule, for while the part grafted remains sound, the margin where spontaneous healing had occurred, is apt to break down, and thus a narrow line of ulceration appears at the edge of the ulcer.

After the layer of granulations has been removed and the newly healed edge of the ulcer has been cut away, the bleeding must be arrested completely before the grafts are applied. The most rapid method is to pour a few drops of adrenalin chloride (1 to 1000) solution over the raw surface, when the oozing ceases immediately. If adrenalin be not at hand the following plan will be found satisfactory: any spouting vessel is clamped and a large piece of sterilized gauze or thin sheet rubber is applied over the raw surface of the wound; outside this, several sponges are placed and a sterilized bandage is bound firmly over them. If the sore be small and an a.s.sistant be available, he may apply the pressure. Pressure is employed indirectly through the protective in this way, because if it were made directly upon the surface of the wound by means of the sponges, bleeding would recommence when the latter were removed, as they stick to the raw surface.

While the bleeding is being arrested the surgeon cuts his skin grafts from any part of the body, as he thinks fit As a rule they are taken from the front of the thigh, but the side of the abdomen may be selected. The area from which the grafts are to be cut is disinfected, and the surgeon grasps the limb from behind with his left hand in such a way as to make the skin over the front of the thigh as tense as possible; in doing this he pushes the soft parts well forward so as to make the anterior aspect of the limb as flat as possible. The skin is further put on the stretch vertically by an a.s.sistant, who pulls it upward and downward. These precautions are important, as without them it is almost impossible to cut a graft of even width. The razor, which should have a very broad blade, is dipped into a boric acid solution and is kept constantly wet with it whilst the grafts are being cut.

Unless this be done, the graft adheres to the blade and may be either partially or wholly cut through before a sufficient length can be obtained. The razor is made to penetrate through about half the thickness of the skin, and then, by a lateral sawing motion, the grafts are cut as broad and as long as possible. After a little practice it is easy to cut them about two inches in breadth and about four or five inches in length.

If one graft be insufficient, it is best to slide it off the razor and leave it on the bleeding surface; in this way it is kept warm and moist. Some surgeons put the graft into warm saline solution, and it is said to then spread out more easily afterwards. Small skin grafts can be cut under local anesthesia.

+Application of Grafts.+ When a sufficient number of grafts have been cut, the bandage, sponges and protective are removed from the raw surface of the ulcer and the grafts are applied to it if the bleeding has stopped, as is generally the case. The raw surface usually has a thin layer of blood-clot upon it, and this should be wiped away.

Each graft is lifted with forceps or the fingers and applied with the cut surface downward, and then is carefully unfolded by means of two probes and stretched evenly over the surface. The grafts should overlap the edges of the skin and also each other, so that no part of the raw surface is left exposed, for granulations always spring up on the uncovered parts and are apt to destroy the grafts in their vicinity; moreover, a thin scar is left at these points which may break down subsequently. The graft is always thinner at its edges than at its centre, and it is these thin edges which overlap each other or the margin of the skin; there is no real sloughing of these overlapping portions.

The dressing should be left on the grafted surface for about five days; in some cases even for a week. If the wound be aseptic, no suppuration or decomposition takes place beneath it. Before being removed, the dressing should be thoroughly soaked with a 1 in 2500 sublimate solution, for otherwise it may stick at the edge and adhere to the graft, which may thus be peeled off, unless great care is taken. The parts should be gently cleansed with the same solution, and a dressing similar to that put on originally should be employed for about another week. At the end of that time the grafts are fairly, firmly adherent and then a 5 per cent, boric acid ointment is the best application.

It will be found that even at the first dressings the grafts present a pink color and are adherent to the deeper surface, though they are still readily detachable. In the course of about a week the old cuticle peels off, but no raw surface is left. Later on, there is a great tendency to the formation of new epithelium, cornification, and drying-up, and it is to avoid the latter condition that ointments are so useful; in fact, until the scar is absolutely sound, it is well to keep the surface covered with some greasy application, the best being the 5 per cent, boric acid ointment.

For many months the grafted surface is likely to scale or crack, and this might prove a starting-point for the occurrence of sepsis which would cause the newly grafted area to slough. It is important to keep the scar as supple as possible, and therefore it should be constantly anointed with cold cream, vaselin, or lanolin. Grafted surfaces upon the face, however, do not manifest this tendency for any length of time.

+Time Required for Cure.+ It is important to know when the patient may be allowed to walk about after an ulcer of the leg has been skin-grafted. If he begins too soon, the grafts will almost certainly become detached. That this will be so is evident from a consideration of the mode by which the adhesion of the grafts takes place. At first they adhere to the surface of the sore, simply by means of the effused and coagulated length. Cells rapidly spread into this length and in the course of two or three days the s.p.a.ce between the grafts and the raw surfaces is occupied by a ma.s.s of young cells. In this tissue, new blood vessels develop and penetrate into the graft, whilst, at the same time, the cells of the latter grow and a.s.sist in the development of the young tissue and of the blood vessels. Thus the graft becomes vascularized; but for a considerable time the tissue between it and the surface of the sore contains many young blood vessels with delicate walls, and therefore, if the patient stands erect and allows the pressure of the column of blood to fall on these vessels, they rupture, and bleeding occurs beneath the graft and leads to its detachment.

It requires a long time before the graft is firmly incorporated with the tissue beneath by the development of elastic fibres; indeed, it may be reckoned that this union is not complete until from three to six months have elapsed. The graft will, in all probability, be destroyed if the patient walks about within three months of the transplantation. Hence, unless that time can be devoted to the treatment, it is not worth employing skin-grafting for ulcer of the lower limbs. By this, however, it is not implied that it is necessary to keep the patient in bed for the entire time, but merely that the foot must not be allowed to hang down, nor must any weight be borne upon it.

At the end of about six weeks the patient may be allowed to get up and lie on a sofa or sit with the leg on another chair, but the limb must not be permitted to hang down. After about three months he may be allowed to get about, but in order to prevent the detachment of the grafts, he should be fitted with a knee-rest and peg on which he walks, the leg projecting out behind him. If possible he should not put his foot to the ground until six months have elapsed. In cases of sores on other parts of the body, when the erect posture does not cause congestion of the part, the patient may be allowed to walk about after the first three weeks.

+Results.+ The scar which results after skin-grafting performed in this manner is of a satisfactory character, and ulcers which have been intractable for years may be closed satisfactorily by this means. In order to obtain anything in the nature of a permanent cure, however, the prescribed period of rest must be adhered to rigidly.

CHAPTER XX

+LOCAL ANESTHESIA+

+History.+ From Corning we learn that the ancient a.s.syrians alleviated and even entirely prevented the pain incident to circ.u.mcision by compressing the veins in the neck. Unconsciousness was probably induced in this way together with pressure on the carotids.

In India, centuries ago, the effects of opium and of Indian hemp were known and employed, and the ancient Egyptians were also conversant with the soporific effects of many drugs. We learn, from the same authority, much which he gathered from literature about the history of local anesthesia, and it is from Corning's well-known book on local anesthesia that most of this history is quoted.

In Peru, the Spanish conquerors learned that the coca loaf was held in high esteem by the natives, inasmuch as they observed that it was chewed by the high priests and n.o.bility only, the vulgar being denied this privilege except as a reward of great merit or of distinguished valor. The leaf was regarded with awe and superst.i.tion and was supposed to possess supernatural powers. After the fall of the Incas, the Spanish not only permitted but encouraged the general use of the leaf in order to obtain more work from the natives, a result which the drug seemed to effect. It was also a source of great revenue to them and was sold at exorbitant profit to the natives who became enslaved to its effects but were able to endure great hardship while under its influence.

Chemists throughout the world, recognizing the potent action of the coca leaf, were soon engaged in the effort of extracting its active principle.

In 1859, after many had tried and failed, cocaine was evolved from crude extractives. Authorities differ as to whether it was Mann or Neimann, a pupil of Woehler, who first presented cocaine to the chemical world; however, fifteen added years elapsed before practical use for it was found. In 1862, Professor Schraff discovered that the tip of the tongue was rendered numb, and insensible when a little of the cocaine alkaloid was applied to it and that it remained so for a considerable length of time. Significant though this experiment was, the action of cocaine on the nerve-filaments was not recognized and the matter was not followed up until Dr. Karl Koller, of Vienna, began his experiments which resulted in a universal awakening to the use of a substance which, though known, had been allowed to remain unnoticed for ages.