1. sterile water;2. ordinary saline solution (a teaspoonful of salt to a pint of water);3. saturated solution of boric acid (prepared by dissolving a teaspoonful of boric acid powder in a pint of water);4. Thiersch’s solution (prepared by dissolving 15 grains of salicylic acid and 90 grains of boric acid in a pint of water);5. Burow’s solution (a solution of aluminium acetate prepared by dissolving 675 grains of alum and 270 grains of lead acetate in a pint of water.U.S.P. formula);6. solution of bichloride of mercury (varying in strength from 1 to 3000, to 1 to 10000);7. 2 per cent. solution of creolin or lysol;8. U.S.P. lead and opium wash;9. aqueous solution of ichthyol (varying from 5 to 50 per cent. according to the indications);
1. sterile water;
2. ordinary saline solution (a teaspoonful of salt to a pint of water);
3. saturated solution of boric acid (prepared by dissolving a teaspoonful of boric acid powder in a pint of water);
4. Thiersch’s solution (prepared by dissolving 15 grains of salicylic acid and 90 grains of boric acid in a pint of water);
5. Burow’s solution (a solution of aluminium acetate prepared by dissolving 675 grains of alum and 270 grains of lead acetate in a pint of water.U.S.P. formula);
6. solution of bichloride of mercury (varying in strength from 1 to 3000, to 1 to 10000);
7. 2 per cent. solution of creolin or lysol;
8. U.S.P. lead and opium wash;
9. aqueous solution of ichthyol (varying from 5 to 50 per cent. according to the indications);
10. black wash (made by dissolving 64 grains of calomel in a pint of lime water—this solution only being used in luetic cases).11. white wash (prepared by mixing zinc oxide, 2 drams, solution of subacetate of lead, 3 drams, glycerine, 4 ounces and lime water, 4 ounces);12. Dakin’s solution (hypochlorite of soda), prepared as follows:
10. black wash (made by dissolving 64 grains of calomel in a pint of lime water—this solution only being used in luetic cases).
11. white wash (prepared by mixing zinc oxide, 2 drams, solution of subacetate of lead, 3 drams, glycerine, 4 ounces and lime water, 4 ounces);
12. Dakin’s solution (hypochlorite of soda), prepared as follows:
Put the chlorinated lime in a 12 litre flask with 5 litres of ordinary water and let stand over night. Dissolve the sodium carbonate and bicarbonate in 5 litres of cold water; then pour this into the flask and shake it vigorously for a minute and let it stand to permit the calcium carbonate to settle. After half an hour, siphon off the clear liquid and filter it to obtain a perfectly limpid product. The antiseptic solution is then ready for surgical use: it contains about 0.5 gm. per cent. of sodium hypochlorite with small amounts of neutral salts. It is practically isotonic with blood serum. Never heat the solution, and always keep it from the light. If in an emergency it is necessary to triturate the chlorinated lime in a mortar, do so only with water, never with the solution of the soda salts.
This solution has been used extensively abroad in the treatment of infections and wounds and has given splendid results.
(A proper quantity of Dakin’s solution for office purposes would be about one-tenth of the prescription above given.)
These are employed either as antiseptics or as astringents or for both purposes. Their use is limited, and they are employed only where the secretion is scanty.
Among the various powders used are: aristol, dermatol, boric acid, orthoform, calomel, protonuclein, zinc oxide, alum, scarlet red, etc.
Thymoliodide, oraristol, is a splendid antiseptic powder and enjoys the advantage over iodoform of being inodorous.
Iodoformshould only be used in tubercular conditions.
Dermatol, orbismuth subgallate, combines the astringent and mildly antiseptic qualities of bismuth and gallic acid.
Boric acidis mildly antiseptic.
Calomelshould only be used in syphilitic conditions.
Zinc oxideandalumare both astringent.
Scarlet red (5 per cent.) with boric acid (95 per cent.) is indicated for the stimulation of granulations.
Solutions.Among the various solutions used are silver nitrate, in various strengths, zinc and copper sulphate, ichthyol, balsam of Peru, nitric acid, sulphuric acid, trichlorand monochloracetic acid.
Silver nitrateis employed for its astringent action, as are also thecopperandzinc sulphates.
Balsam of Peru is used for its stimulating action.
The stronger acids are employed for their escharotic qualities.
“Red wash” (made up from the following formula: zinc sulphate 20 grains, compound tincture of lavender 30 minims, distilled water to make 8 ozs.) has a powerful astringent action and promotes cicatrization, especially when there is a tendency for the granulations to become exuberant.
In the treatment of chilblains, a strong astringent is desirable to constrict the diluted capillaries.
The strongerlotio albaof the national formulary, containing equal parts of the saturated solutions of zinc sulphate and potassium sulphuret, is markedly astringent and has a drying effect upon the skin.
Styptics.These may act either by causing clot formation in the cut arteries, or by causing the retraction of their edges. In the latter class are included such drugs ashydrastineandadrenaline.
The disadvantage of using these drugs lies in the fact that secondary hemorrhage is possible when their constrictor action is over. The styptics causing clot formation are therefore to be recommended. They should be non-irritating, antiseptic, and styptic, at the same time. Such a preparation is practically unknown.
Peroxide of hydrogenon a pledget of cotton, placed over the bleeding area, may effect a clot formation.
The U.S.P.liquor ferri subsulphatis, better known as Monsel’s solution, is the best and most effective styptic that we have. Monsel’s solution, however, is not antiseptic and entrance of bacteria into the wound is possible, unless, it is applied with a sterile applicator or is dropped directly upon the wound from the bottle.
The U.S.P.tincture of iodinein equal parts of water, applied to the bleeding area may, besides sterilizing it, stop bleeding.
Should none of the above effect a stoppage of the bleeding, other means must be sought. A bit of sterile gauze pressed quite firmly against the area, should next be tried. If this fails, a wooden applicator, prepared with Monsel’s solution may be employed. A cotton wound applicator, unless dipped into a strongly antiseptic solution, contains millions of bacteria from the fingers. The use of the ancient styptic stick of alum, copper or silver is discountenanced everywhere as uncleanly.
Solvents.Under this heading, those substances which are known to soften tissue will be considered.
Sodium hydroxide, up to a saturated strength, or an ointment ofsalicylic acid, 5 per cent. to 50 per cent., dependingupon the density of the tissue to which it is applied, are the ones commonly used.
These two drugs have the power to macerate dry, hard tissues.
Experience is necessary for the proper use of tissue solvents as the length of time that they are allowed to act is of as much importance as the strength of the solution.
Sodium hydroxide solution can be instantly neutralized with any acid and for this reason is preferable.
Ointments.In the list of ointments, the much vaunted virtues of advertised compounds are usually found.
Ointments and oils are used in the treatment of wounds and ulcers, either to stimulate granulations or to soften thick epidermis.
Ointments should never be used where there is a profuse discharge, as eczema is a complication which very often follows such treatment.
A great many different kinds of ointments are used and among these are:
Sulphurin 10 per cent. strength, orammoniated mercuryup to 5 per cent., where a paraciticide is indicated.Balsam of Peruin 10 per cent. strength for the stimulation of granulations; orbalsam of Peruandcastor oil, equal parts; alsoboric acid, orichthyolfor their antiseptic properties.Ten per cent.mercurial, for syphilitic cases.Lassar’s paste(which consists of salicylic acid, one dram, starch and zinc oxide, each one ounce, and vaselin to make 4 ounces) is used when there is an eczema present.
Sulphurin 10 per cent. strength, orammoniated mercuryup to 5 per cent., where a paraciticide is indicated.
Balsam of Peruin 10 per cent. strength for the stimulation of granulations; orbalsam of Peruandcastor oil, equal parts; alsoboric acid, orichthyolfor their antiseptic properties.
Ten per cent.mercurial, for syphilitic cases.
Lassar’s paste(which consists of salicylic acid, one dram, starch and zinc oxide, each one ounce, and vaselin to make 4 ounces) is used when there is an eczema present.
One of the oldest as well as one of the best applications is balsam of Peru, which has a powerful effect in increasing the growth of granulations, but often after this has occurredthe granulations are apt to become exuberant with little tendency to cicatrization.
The ointment which has given the best results isscarlet red, an aniline dye, which is known chemically as a sodium salt of a disulphonic acid derivative. Scarlet red (Biebrich) was originally prepared as a dye for wool and silk, and is so named because of the fact that it was first manufactured in the town of Biebrich. It was first used for medicinal purposes in 1907 in an 8 per cent. strength; because this strength was found to be too irritating, it was alternated with a bland ointment every 24 hours. It is now used only in strengths varying from one-half to five per cent., for the latter has proved to be as strong as necessary. When applied to granulating surfaces, scarlet red is sometimes absorbed in sufficient amount to color the urine a bright red, and a number of acute cases of nephritis have been reported from its use.
Its application to granulating surfaces causes healing, not by the formation of scar tissue, but in every case by producing a high grade of normal skin (this can be demonstrated by sections), which very soon becomes freely movable on the underlying tissue. The return of sensation in the healed area takes place from the periphery inward, instead of upward from the underlying tissue.
Scarlet red ointment should be applied in the following manner: after thorough cleansing of the part with tincture of green soap and water, then ether and finally 93 per cent. alcohol, the ointment should be spread in a thin layer over the entire surface on a piece of sterile gauze, and over this an ordinary dry sterile dressing. If the ointment is applied too thickly it may cause granulation tissue to break down, and for this reason it should be spread in a thin layer upon the granulating surface or its edges. Usually the dressing should be left undisturbed for from 24 to 48 hours, then reapplied, as indications warrant. The patient should invariably be informed that the dressing will be stained red, so as to forestall unnecessary alarm, due to the belief that a hemorrhage has occurred. He shouldalso be apprised of the fact that stains on the linen are hard to eradicate. In removing the dressing, if it is adherent to the granulations, some peroxide of hydrogen should be used to loosen it. The skin about the granulating surface is best cleansed by benzine as this removes all traces of scarlet red better than any other solution. The three formulas that are recommended are the following:
The first is indicated where its use is desired over a large area and for a long time; the second, where an astringent action is required because the granulations are profuse; the third, where the granulations are sluggish and require stimulation.
The ointment in a 10 per cent. strength is not recommended because it is too irritating.
In cases of chronic leg ulcers, especially those associated with enlarged veins, it is impossible to effect a cure until the chronic congestion of the limb is relieved and the blood supply of the part approaches the normal.
Often all that is necessary is a gauze, muslin or flannel bandage, properly applied over the dressing and extending from the ankle to the knee.
A rubber bandage when applied with moderate, even pressure, has for its purpose the relief of congestion, but in a great many cases the rubber has an irritating effect on the skin.
When the granulations are almost on a level with the surrounding skin, and also when there is considerable thickening of the edges of the ulcer, the best means of keeping up an even pressure and causing absorption of the thickened margins, as well as of hastening the epithelial growth,is to apply zinc oxide adhesive plaster in strips, one-half to one inch in width. These strips should overlap to the extent of about one-third of their width; should extend about three-fourths of the way around the limb, and should be evenly and smoothly applied. They should be started about one inch below the ulcer and should run from two to three inches above it.
Bandaging of Leg.The final stage after the dressing has been put on, consists in the application of the bandage. A bandage possesses advantages over strapping in being less irritating to the skin; in being more quickly put on and taken off; in being more easily removed without disturbing the surface, and in more completely allowing the formation of the granulations.
The bandage is also superior to a laced stocking, as the latter does not properly embrace the foot.
The bandage material can be either gauze, muslin or flannel. The last is considered the best because this material is thin, yielding and elastic and yet almost any degree of compression can be exercised with it.
In edematous swelling in general, the flannel appears very suitable, as it is soft to the skin and accommodates itself to the greater or less distension of the limb, arising from the increase or diminution of the fluid. The bandage should be at least six yards long, if required for an ordinary adult, and the width should be from two to three inches. Every portion of the limb, from the toes to the knees, should be equally and evenly compressed. Compression is of such absolute importance that without it everything else will be comparatively ineffectual. This being so, very much will depend on the manner in which the bandage is employed.
Without practice, it is not easy to properly apply a bandage to the leg, and probably this difficulty is the chief reason why preference is often given to adhesive plaster, as this sticks wherever it is put.
The blistering and excoriation often produced by strapping,and the time consumed in its application, are sufficient reasons for acquiring skill in the art of bandaging; an art whose comforts and advantages are appreciated by the patient.
Before using, the bandage should be rolled up very tightly, so that it may be grasped easily and held in the hand firmly without slipping. In putting it on, unwind only that portion which is being applied to the limb, because if it be loose in the hand, or if a considerable piece be unrolled at a time, it cannot be applied firmly or smoothly. The bandage should always be carried up to the knee, even if the ulcer or wound be seated on the lower part of the leg or on the foot itself, as the object of its application is not merely to cover the ulcer but also to support the vessels of the limb. If the bandage be discontinued on any part of the leg, it is liable to become loose and fall down.
It is desirable also that the patient should not wear a garter above the bandage, as anything unequally tight in the course of the veins is calculated to obstruct the free passage of the blood.
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 bandagethe 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 circumstances 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 thenmade 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 recumbent position with the leg elevated, but when circumstances 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 gasrange 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 talcum 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.
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 appliedvery 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 passing beneath it, out through the skin on the other side, is one method. By tightening these sutures, over a button 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 pass 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 thehealing of a chronic ulcer, the continued existence of which and failure to heal having been due to its thickened, adherent base and edges. Circumcision 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.
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 circumstances 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 scraped 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 sterilizedgauze 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 assistant 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 assistant, 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 wellto 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 space between the grafts and the raw surfaces is occupied by a mass 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 assist 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 lowerlimbs. 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.
History.From Corning we learn that the ancient Assyrians alleviated and even entirely prevented the pain incident to circumcision 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 nobility 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 superstition 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 potentaction 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.
Its anesthetic effect upon the eye was demonstrated by Koller at the Opthalmologic Congress at Heidelberg in 1884. Dr. H. D. Noyes was first to direct the attention of the American practitioners to Koller’s results in the use of the drug. Its introduction was one of the greatest triumphs of modern surgery. It makes possible the discard of the systemic anesthetics in all minor surgical operations and also in many operations of considerable magnitude.
In the laboratory of Professor Stricker, Koller experimented on the eyes of a number of animals and thus reports his findings:
“A few drops of a watery solution of muriate of cocaine dropped on the cornea of a guinea pig, rabbit, or dog, or instilled into the conjunctival sac in the ordinary way, caused, for a short time, a winking of the eyelids, evidently in consequence of a slight irritation. After one-half to one minute the animal again opens its eyes which gradually assume a staring look. If now the cornea is touched with a pin head (in which experiment we have carefully avoided touching the eyelashes), the lids are not closed by reflex and the eyeball does not move, the head is not thrown backas usual, the animal remains perfectly quiet, and, on application of a stronger irritation we can convince ourselves of the complete anesthesia of the cornea. In this way I have scratched and transfixed the cornea of the animals used for experiment with needles, and have excited them with electric currents so strong as to cause pain in my fingers, and to become quite intolerable to the tongue. I have cauterized the cornea with the nitrate of silver stick until it became milky white; during all of this the animal did not move. The last experiment convinced me that the anesthesia involved the whole thickness of the cornea and did not affect the surface only. But if I incised the cornea, the animals manifested intense pain, when the aqueous humor escaped and the iris prolapsed. I have been unable hitherto to decide, by experiments on animals, whether or not the iris could be anesthetized by dropping the solution into the corneal wound, or by prolonged instillations into the conjunctival sac; for experiments to test the sensibility of non-narcotized animals are very complicated and difficult and do not yield unambiguous results. The last question which I subjected to experimentation on animals, viz., whether or not the inflamed cornea could be anesthetized by cocaine, was answered in the affirmative. The cornea in which I had incited a foreign-body-keratitis, became as insensible as a healthy one.
“Complete anesthesia of the cornea from the use of a two per cent. solution lasts ten minutes on an average. After such successful experiments on animals I did not hesitate to use cocaine also to the human eye, trying it first on myself and on some of my friends, and then on a great number of other persons, obtaining, without exception, the result of a perfect anesthesia of the cornea and conjunctiva.”
Soon after Dr. Koller’s report appeared, cocaine was used for a great many operations upon the eye, and its application to mucous membranes in general was soon taken up by practitioners everywhere.
Rectal, vaginal, otologic, rhinologic, oral and urethralanesthesia were soon found to be easy of accomplishment and many operations in these fields were performed under cocainization. The hypodermic injection of cocaine was experimented with and reported upon in 1884 by Drs. N. J. Hepburn, R. J. Hall, and Halsted.
Nerve Pressure; Anemia.That motor and sensory paralysis followed pressure upon a nerve has been well known for many years, and this has been utilized in the effort to produce anesthesia, artifically by applying a rubber tube or bandage around a finger or extremity, with the hope that “ligation anesthesia” would follow the arrest of circulation. This, however, has been unsuccessful as all that was thus accomplished was a slight sensation of numbness with no arrest of the sense of pain. This method could only be successfully carried out, were the nerves themselves subjected to sufficient pressure to injure them. Return to normal sensibility and motor function could not be expected for months.
Cold.The addition of common salt to ice hastens its liquefaction and consequently renders the mixture more cold. This knowledge has been applied in a method of producing anesthesia of limited areas of the skin. A gauze bag of the correct shape and size is filled with salt and ice mixed, and applied to the area to be anesthetized.
This method was used as far back as 1848, by Arnott, but was soon improved upon by Richet and others who used ether or rhigolene sprayed on the part to be anesthetized. It was found that extremely low temperatures could be obtained in this way, especially if a current of air were blown across the field of operation to hasten evaporation, and that a good local insensibility could be brought about if the circulation of warm blood could be either stopped or retarded with an Esmarch bandage or tourniquet. The method of obtaining local anesthesia through the agency of cold was found to be best accomplished by ethyl chloride andthis substance is used in preference to any of the others previously mentioned, at the present time. Some years ago Dr. Martin W. Ware of New York experimented with both ethyl chloride and ethyl bromide and he found that the former was more serviceable in producing local anesthesia.
The Sensibility of Various Tissues.Karl G. Lennander, of Upsala, Sweden, shortly before his death, completed a chapter on local anesthesia for Keen’s “Surgery” in which is set forth an elaborate account of the sensibility to heat, cold, pressure, and pain of the various nerve terminals throughout the body. In this great work he has given the world the results of many experiments on living tissues, experiments investigating the degree and kind of the tissues sensibilities; thus it is learned that “all internal organs receiving their nerve supply only from the sympathethic nerve and from the vagus, below the branching-off of the recurrent nerve, have no sensation, and that the abdominal and pelvic viscera are devoid of nerves to convey the sense of pain, heat, cold, or pressure.”
From the same authority we are taught that the parietal peritoneum is highly sensitive but that the visceral covering is devoid of all sensibility, enabling the operator much freedom of manipulation within the abdominal cavity.
In a work of this limited size the sensibility of the various tissues cannot be fully treated but it should be borne in mind that the integument and the subcutaneous tissue, fat and muscles as well as the tendons, their sheaths, the muscles and periosteum and perichondrium covering the bones and cartilages throughout the body, are all highly sensitive to pain. It is also equally true that the bone substance, the bone marrow, and the cartilages are devoid of any of the four modalities of sensation. Articular surfaces covered with cartilage have no sensation, neither have the fibrocartilages any sensation.
Effect of General Anesthesia.Local or regional anesthesia is obviously the method of choice in all cases in whichit is applicable. Not only is it desirable in the minor surgical operations and the more important ones upon patients suffering with a cardiac or nephritic derangement, where a general anesthetic is positively contraindicated, but in every instance where it is at all possible, the dangers and annoyances of general anesthesia should be avoided, and the regional or local anesthesia should be employed.
Among the advantages, aside from the number of assistants required and the discomfort immediately following the administration of a general anesthesia, are the absence of remote ill effects of the invasion throughout the entire system of a noxious chemical substance and its direct deleterious effects on many large organs such as the lungs, heart, kidneys, and liver, and the assurance, when a proper drug, dosage, and technic are employed, that death cannot be ascribed to the anesthetic.
Of remote ills of general anesthesia no estimate can be made, but that they are legion and of great severity is established. Deaths from general anesthetics in persons apparently able to bear them well, are extremely numerous. It has been estimated that one in fifteen thousand succumbs from ether anesthesia and this number would probably swell greatly were it possible to obtain the exact figures. Even this minimum of danger does not exist in local anesthesia.
An accurate knowledge of the neural anatomy of a particular region enables the operator to anesthetize large areas and to operate with entire freedom from the necessity of observing the appearance and conduct of his patients, many of whom, notably the alcoholic ones, behave badly, become cyanotic and breathe intermittently when under the effects of inhalation anesthetics. The absorption into the body of the substances employed by inhalation may also exert a baneful influence by reducing the powers of resistance upon an economy already lowered by disease, and also by retarding convalescence.
Advantages of Local Anesthesia.In minor or trivial affairs the elimination of pain is not to be considered lightly, for every patient, even the strongest, will appreciateanything which will expedite a cure and at the same time will relieve him of suffering. Rather than lose time from their work or suffer the nausea and dangers of general anesthesia, these patients often bear for years conditions which could easily be cured by operations under local anesthesia. In this class one must first think of hemorrhoids; of cysts; of fatty tumors; of foreign bodies in the hands and feet; of verruca and of ingrown nails. These conditions would be promptly relieved were the element of pain in surgical interference not to enter as a factor.
With a perfect technic, local anesthesia can also be employed with entire satisfaction for certain major operations, where the subject is suitable. Thus, herniotomies are performed with entire success, especially those cases complicated by strangulation in which the dangers arising from fecal vomiting and inspiration pneumonia, are greatly decreased by omitting the general anesthesia.
In many of the more severe conditions not to be classified as minor surgery, the surgeon may consider the comfort of the patient and his own convenience and employ local in preference to general anesthesia, even tho the patients may be of the most robust type.
In this group may be mentioned benign tumors at any visible part of the body, hernias, many scrotal and anal diseases and some conditions peculiar to the extremities, such as varicose veins. These conditions lend themselves kindly to local insensitization.
In certain emergencies where an operation must be performed immediately, such as tracheotomy, thoracentesis and strangulated hernia, local insensibility is imperative. In these operations local anesthesia is also more desirable because of the ill effects of vomiting, which are thus eliminated.
Weakness of the patient enters also as a demand for the exhibition of a local anesthesia in such operations as resection of a rib for empyema, in which instance the action of the heart or lungs is embarrassed. Other operations performed under local anesthesia for the same reason (weaknessof the patient) are the exploratory operation for a probable inoperable cancer and the palliative operations such as gastrostomy, enterostomy and colostomy.
There are, however, valid objections to the general application of local anesthesia and the cases for its use should be selected with care. It does not produce relaxation nor does it give the surgeon perfect control over his patient. These are considerations which must be taken into account, especially in operating on patients of highly nervous temperaments. Though the patient may be convinced that he will suffer no pain, the mental attitude toward the local anesthesia, together with fear, may operate so strongly as to constitute a shock to the nervous system so great that a general anesthetic should be used and the local method abandoned, even were it apparently indicated.
Again, the injection of anesthetic drugs in cicatrical and inflamed tissues is quite difficult of accomplishment and because of the peculiarity of these tissues, diffusion throughout a given area is imperfect, hence insensibility is not complete.
The extravagant claims of enthusiastic advocates of this method of anesthesia have retarded its progress. Thus, in the hands of the competent operator it was given but a perfunctory trial to be discarded as impossible. At the present time, however, local anesthesia bids fair to become the method of choice, other things being equal, for many major operations not yet thus performed. Recent investigations alone these lines have developed methods of its application whereby it is possible to render insensible large areas of the integument, and regional anesthesia is performed by anesthetizing nerves proximal to the seat of operation, thus rendering amputations feasible.
A single element which has entered as a factor in retarding the progress of local anesthesia in general surgery,is that of regarding the operation as one fitted to the method rather than to the patient under consideration. It is obvious that this is a fallacy and the main issue in deciding between general and local anesthesia is: what will the patient best tolerate? In coming to a decision in the matter one should make a general survey and weigh first the general health of the patient; whether he be in perfect systemic condition or undermined by disease, whether the shock will be greater from one method than the other, and whether the part of the body to be operated on is one which will lend itself better to one method than to the other.
These elements are being and will continue to be considered as preliminary to operative procedure and in consequence, general anesthesia will cease to be given in a routine way.
The first essential to the successful production of local anesthesia is a proper equipment and one that is in good working order. Not only is it necessary to employ the best drug to this end but also to use a syringe having perfect mechanical construction and one not injured by boiling; as also needles of the length, lumen and shape suitable for the surface to be injected.
The old leather pocket syringes, on account of their not bearing water at high temperature without deterioration, should not be employed; this applies also to that variety of glass barreled metal-mounted syringe in which the glass is screwed into the metal end pieces.
The best syringes are those made of all metal or of all glass, the latter being preferred because one may see the contents and express out the air before injecting. Syringes of this type, because of the accurate fitting piston, must be thoroughly dried out after use, as the piston may stick fast within the barrel. All-glass or all-metal syringes must be selected with care as they are often imperfect, the calibre of the barrel being unequal in different parts of its length causing the piston to fit tightly in some parts, and thus towork with difficulty; and in other parts fitting loosely, allowing the fluid to escape backwards.
Syringes are also made in various sizes and shapes to meet certain requirements. For the edematization of large areas of loose tissue, where a considerable amount of a weak solution is intended, the use of a large barreled syringe will be found to save time and the annoyance of refilling.
For such work a five or ten c.c. syringe would be the most useful. The ordinary hypodermic syringe is about of two c.c. capacity (thirty drops), and serves the purposes of every-day work. It does very well for the amount of an anesthetic solution employed in opening an abscess or in the removal of a small cyst or lipoma or papilloma.
A barrel, large in diameter, requires more pressure on the piston in its operation unless the needle employed is also correspondingly large. For this reason, if the tissue in which the solution is to be injected is not loose or cellular, it will be found better to use a syringe in which the barrel is long and narrow. Such is the shape of the syringe intended for the injection of the gums, the peridental membrane, and also for the periosteum, cartilage or bony cellular structure. A long instrument is also required for use in the large cavities of the body such as the mouth, the vagina, or the rectum. In these localities, an extension fitting is often required to lengthen the instrument sufficiently to reach the desired part. It is also possible to attain this end by using a long needle; this, however, sacrifices rigidity.
For accomplishing the best results, the needles must also be selected for the work at hand. For the initial puncture in sensitive or inflamed tissue, it is proper to use a needle of the finest lumen so as to cause the least possible amount of pain. The ordinary needle, which comes with the usual hypodermic outfit, is about the proper length for the ordinary work already mentioned, but could be improved upon for anesthesia by being made a little finer in calibre. This length (three-quarters of an inch) will be frequently found insufficient to reach the deeper tissues and in theremoval of a more or less rounded growth, a longer needle must be selected at the start. Curved or angular ones are only needed in dentistry, where strength is also a consideration. Strength is afforded in those of short length by means of a reinforcement at the hub. Needles so augmented may also be of use in operations upon bone or dense structures in general; the curve, however, is not essential.
The surgeon should be fully conversant with the details of the operation which he is about to perform. His work should be definitely in his mind, for in operations under local anesthesia, there is no justification for a change of procedure after the beginning of the work. Account should be taken of the nature of the tissues to be anesthetized, for it is known that cicatricial tissues and inflammatory areas do not lend themselves to the action of these drugs. In a cicatrix, the diffusibility of the solution is impeded, and in an inflammatory or necrotic tissue, the changes in the quantity and quality of the fluids present, alter the action of the anesthetic.
In considering the personal element of the patient one meets a difficulty which is by no means minor, and full explanation for the selection of the local anesthetic with many assurances of the painlessness of the operation are frequently necessary. This is especially true with one of highly emotional temperament, and, to allay fear in such a patient is not always easy.
Whatever may be said regarding the mental state of the patient who is to receive an anesthetic, whether general or local, the surgeon must remember that to be calm does not always lie within the control of his subject, and it will be found that a hypodermic injection of morphine (gr. one-eighth to one-quarter) an hour before the start of the anesthetic, will often render possible the use of the injection method in a patient with whom it would otherwise have been impossible. Morphine injections, as suggested, are of advantage in patients on whom a major operation is contemplated; they loosen the musculature and diminish the sensations of parts not anesthetized.
The deliberate and confident manner and word of the surgeon go a long way in guiding the feelings of his patient, and a worried or apprehensive surgeon makes for a doubtful and sensitive patient, ready to cry out at the first prick of the needle. Therefore it is a part of good general technic for the surgeon to deport himself in a way conducive to cheerfulness, and conversation must be guided along these lines.
There are many who will writhe and groan at sensations (which they will admit later were not painful) incident to local anesthesia, such as the grating vibrations of instrumentation. Such a patient is not well fitted for the method and it is for the discerning surgeon to recognize such in advance, that he may operate under the most favorable circumstances.
Preparation of the Patient.Proper evacuation of the bowels and a stomach free of undigested parts of a previous meal, are desirable. The subject of an anesthetic should not be purged or starved as these are weakening processes and also disturb the tranquility so essential to a perfect anesthesia. The skin should be prepared so as to accomplish surgical cleanliness without irritating it so as to retard healing. It was once thought that soap, water, alcohol, ether and bichloride were absolutely necessary to this end. It has, however, been found that iodin, applied in the ten per cent. tincture to the site of incision, fulfills every requirement. Where shaving is necessary, it should be done first. In operations about the anus and scrotum, iodin is contraindicated because of its irritating properties; it is painful in these parts and dermatitis is frequently the result of its use.
Instruments.The instruments should be prepared and ready before the anesthetic is given, regardless of the form of anesthesia employed. The surgeon’s hands should be rendered aseptic, no matter how trivial the procedure before him, and every precaution should be taken to guard against infection, which is always possible in any surgical procedure however insignificant.
Technic.Various methods of accomplishing the insensitization of a part may be employed. Thus, if the skin alone is to be incised, it alone will require injection and by careful insertion of the end of the needle it may be kept just under the epidermis, thus injecting the anesthetic endermatically in and about the papillae of the papillary layer.
Endermic Method.This method is an end-organ anesthesia, and the solutions employed are strong and act because of their drug content. It is not in any sense a pressure anesthesia. The skin should be picked up and pinched hard for the better insertion of the needle directly into the skin substance. It is therefore endermic and the skin is seen to become blanched as the needle advances delivering its solution on the way. But little of the fluid is pressed out as the needle advances. When the syringe is empty or the needle has advanced to the limit of its length, refill and insert just inside of the last blanched spot and proceed in a line until the end of the contemplated line of incision is reached.
Pressing out too much of the solution at one time causes a burning sensation and should therefore be avoided as the only pain should be that of the initial prick of the needle. Care, however, should be taken to inject just sufficient of the solution to penetrate beyond the zone of operation laterally, to insure sufficient space for the insertion of sutures into anesthetized tissues. Only a small quantity of fluid is necessary in this procedure as it comes in direct contact with nerve terminals. By touching the injected line with the needle in several places along its length and inquiring of the patient if it is felt, we may make sure of the completeness of the anesthesia before making the incision which should begin and end inside the anesthetized area.
Subdermic Method.An appreciable area of skin and subcutaneous tissue may be incised by anesthetizing as previously described, together with depositing the fluid well under the skin, thus affecting many terminal nerve branches before they reach their final distribution in the skin, and widening the anesthetized area considerably.
This method is applicable to such work as the removal of small growths, and the deep incision of a carbuncle. Beneath the skin in the loose connective tissue the fluid is deposited and causes anesthesia by acting upon the nerves just before their emergence into the skin. The two methods may be combined. It is not possible to inject directly into thin skin or mucous membrane and it is therefore employed in such operations as circumcision, where the nerve terminals must be anesthetized by the diffusion of the anesthetic from its position under the skin. A little time should be allowed before beginning the operation to permit of the diffusion of the drug. This applies also to such operations as that for ingrown toe-nail where the deeper tissues down to the root of the matrix are involved.
Edemitization Method.This is the method of Schleich and it is to him that the credit must be given for a procedure which has done more to encourage the use of local anesthetics in operative surgery than any other. He employed weak solutions of cocaine and other local anesthetics in great volumes of water in order to gain the combined action of both drug and of pressure. The method is described under the heading of “Cocaine.” It was designed to obtain anesthesia with cocaine with the elimination of the toxic effects of the latter.
There are decided disadvantages to the filling up of the tissues with fluid; healing is delayed; relations are distorted and coaptation of the edges is difficult. This is probably the method of selection where an indefinite amount of manipulation is expected and where the length and depth of the incision may need to be augmented. A large quantity of a very weak solution is employed and the tissues in all directions are injected until visibly distended.
Nerve Blocking Method.By injecting a small quantity of a fairly strong anesthetic solution either directly into a nerve or beneath its sheath, the entire area supplied by it will be anesthetized. This method of nerve blocking may be spoken of asendoneuralwhen the injection is made directly into the nerve trunk, andperineuralwhen made intoits sheath or immediately outside of the nerve. The injection of fluid around nerves too small to inject directly is also spoken of as perineural nerve blocking. (Hertzler).