CHAPTER XVIIICASE RECORDING METHODS
Every case, whether of little consequence or of important nature, should be properly and fully recorded in a thorough and systematic manner. Apart from the value of such a record, to the operating surgeon it often proves of the greatest importance in cases where operations of a purely cosmetic nature are undertaken.
Patients who beg us to make them more beautiful, or less unsightly in the eyes of the ever-critical observer, are the most difficult to please, and often complain, after a few days of constant mirror study, of the parts changed by methods that are the result of years of hard-earned experience, that the nose or the eyes or the ears have not been changed as much as they desired—in fact, so little that their closest friends have failed to evoke ecstatic remarks about the improvement.
This is not unusual with the most intelligent patients and is due to the fact that cosmetic operations performed on an ugly though otherwise normal organ have not yet become very frequent, and while friends are inclined to remark a change in lesser defects, they fail to credit this to the cause, owing to a lack of the knowledge of cosmetic surgery, or their ignorance of the art entirely.
Photographs.—Where a pathological defect, wound, or scar or traumatic deformity is to be corrected, the patient is usually kind enough to permit of photographs being made of the parts to be operated on, but where the defect is hereditary, or the result of age, objections areinvariably raised by all concerned, for fear their pictures will be used in some outlandish way.
The objection to photographs is obvious, since it usually requires visits to a studio, and the necessary loss of time to the surgeon, whose presence is nearly always necessary to secure the proper negative.
This is especially true of the nose. Very few photographers will make a satisfactory sharp profile picture. It is less artistic, but most desired by the surgeon, and when the patient is presented for a second negative after the operation has been performed, the picture varies more or less in pose from the first taken.
It would be well for physicians to have a camera for use in the operating room, and those who can manipulate one will find that taking a 5 × 7 negative the most suitable.
Stencil Record.—For those who cannot provide themselves or bother with a photographic apparatus, the stencil record is recommended.
For this purpose a picture of a normal eye and itslids, a nose, lip or ear, is drawn upon a piece of oiled or stencil paper, or upon any thick, stiff book board.
The paper is laid down upon a plate of glass and the outlines of the picture are cut out, wide enough to allow the sharpened point of a pencil to pass. Where the lines are long it is advisable to allow connecting links to remain at various intervals as desired to keep the stencil stiff and to prevent cut margins from slipping or rolling up. (SeeFig. 521.)
Fig. 521.—Nose Stencil.
Fig. 521.—Nose Stencil.
Fig. 521.—Nose Stencil.
The stencil thus made is laid upon the record card and a tracing is made upon the latter by passing the lead-pencil point along the cut outline.
The stencil is now lifted and the defect sketched into the picture of the normal organ.
If this should be the anterior nasal line, a perfect sketch can be made of the defect by placing a card alongside of that organ and drawing the outline upon it as the pencil is made to glide over the nose, the point facing the card in such a way that a true profile outline is obtained. The card is then cut along the pencil line.
The nasal section of the card is now placed upon the stenciled nose and its outer border traced into or over it, as the case may be, by drawing the pencil point along the outer margin.
The same method may be followed post-operatio. This method can be employed for the other parts of the face as well, as, for instance, the mouth, ears, base of nose, etc.
Distances in measurements should be put into the record drawing to make it more exact.
The Rubber Stamp.—Another method is to make outline sketches of normal parts of the face with India ink upon drawing board and have those reproduced in rubber stamps, using the stamp in place of the stencil and marking in the defect in the manner before mentioned.
The Plaster Cast.—The best method by far, however, and the one found most accurate, is the plaster cast. It is nota difficult thing to make a cast of a nose, eyelid, lip, or ear, and the latter is much more preferable to any other method of record.
For this purpose some modeling clay is required, which is molded into a strip and laid around the part to be reproduced.
This forms a sort of raised ring or border and prevents the overflow of the semiliquid plaster, and avoids the annoyance of trickling the liquid upon other parts of the face about the site of the part worked on; at the same time it permits of neatness and uniformity in the size and shape of the casts to be filed away as records. (SeeFig. 522.)
Fig. 522.—Method of Making Nasal Plaster Cast.
Fig. 522.—Method of Making Nasal Plaster Cast.
Fig. 522.—Method of Making Nasal Plaster Cast.
The skin surface, and hair, if any, within this ring area, before using this plaster of Paris, is now thoroughly coated with clean oil, or petrolatum, applied with a soft sable brush. The inner and upper part of the wax ring is also coated.
If there are openings in the parts of the face, such as the nostrils or the auricular orifice, they should be plugged lightly with dry absorbent cotton, care being taken, however, to avoid distending the alæ.
The plaster is now prepared in a small porcelain or soft rubber bowl by adding warm water to it until the powder, upon stirring, forms an even semiliquid paste.
This is poured first upon the area to be reproduced to fill all the finer crevices and to avoid air holes, and is then put on with a spatula, or wooden slab, until thespace within the clay boundary is properly filled, covering the organ all over with a layer ¼ to ½ inch in thickness on all sides. Over the eyelids a thin coating of plaster should be used, whereas over other parts of the face a thickness of half an inch can be allowed without discomfort to the patient.
It is well at first to make the plaster thick, as the mold is liable to be broken upon removal or in drying. After a little experience splendid results are obtained with very thin walls of plaster.
The plaster is allowed to dry and harden, while the patient is instructed to remain still and silent. If a cast of the nose is made, the patient should refrain from talking and breathe gently through the mouth.
Tapping on the plaster now and then with a lead pencil will show when it has hardened sufficiently to be removed.
A firm, quick pull relieves the mold.
In molds of the ear an anterior and posterior impression should be made, if a cast of the entire organ is desired. This can be done by first applying a layer of plaster to the posterior surface up to the outer rim, allowing this to harden and painting the anterior ear and the exposed plaster border with petrolatum before putting the plaster over it. Upon traction, when set, the plaster will separate readily at the point of the separation.
The removed piece of set plaster is called the mold.
It is allowed to dry thoroughly and then preferably coated inside with a thin coat of liquid petrolatum, which is found to be much better than oil.
A thinly prepared paste of plaster is poured into it at the outer brim and allowed to harden. The best results are obtained by setting the mold into a small pasteboard box in which it is held in proper position and prevents the thin plaster from running over the depressed edges.
By gently tapping the mold when the cast has set, it is made to separate from the latter sufficient to permit of separating or cutting away of the mold inside of it.
The cast, when removed and dry, is coated with white shellac varnish. Upon its reverse side a note is scratched into it, giving the case number, or such information as the surgeon may desire.
The author advises the addition of a small quantity of Armenian bole to the plaster used for the cast, as it gives a less ghastly tint and aids much by its color in the cutting away of the white mold from the cast. Several of these casts, taken before and after operation by the author, have been shown in the preceding chapters.
After operation and healing of the parts a second cast is made.
Hooks can be inserted into the casts, when still soft, to hang them up by, or loops of string or wire are stuck into them, while setting for the same purpose.
Such a collection is not only of great value to the operator, but is a means of constant and absolute record, even to the extent of reproduction by photography.
The necessary data in respect to the method employed in operating, dressing, etc., is to be added to the record as generally done with medical or other surgical causes.
Preparation of Photographs.—There are some cases of which no other permanent record can be made, except by photograph. If these can be obtained, the negatives are to be printed without retouching, the prints being made on silver printing paper of the glossy type to permit of reproduction in half-tone when desired at some future time.
In printing such pictures, the eyes, or other part of the face not operated on, may be obliterated by laying strips of paper next to the negative, the part thus covered coming out white in the positive.
The photographs made of parts to be operated onshould be made as near as the normal size, for obvious reasons of accuracy and measurement.
This can be done by comparing the size of the part to the picture found on the ground glass.
Cameras that do not permit of ground-glass focusing are useless as well as uncertain. Time exposures are necessary for the best results.
Dark backgrounds should be used to get the sharp outlines by contrast. Too much light on the parts, such as direct sunshine, is undesirable, as it makes the parts appear flat and lifeless; therefore a muslin screen is of great value to graduate the intensity of the light, and if this is not at hand, a sheet of paper will answer the same purpose.
In printing make note of the depth of color of the parts most desired to be shown, varying with the different parts of the face. Look to contrast, and in pathological cases have the diseased area printed so that it will stand out forcibly as compared to the fellow organ in health or the normal tissue beyond its border.
To protect photographic records, they should be properly bound in book fashion to avoid scratching, rubbing, or breaking. This not only implies neatness and thoroughness on the part of the surgeon, but also permits of ready reference at all times.
An index to the contents of such a book is a desirable adjunct.