Surgery, with Special Reference to Podiatry Part 29

The stronger _lotio alba_ of the national formulary, containing equal parts of the saturated solutions of zinc sulphate and pota.s.sium sulphuret, is markedly astringent and has a drying effect upon the skin.

+STYPTICS+

+Styptics.+ These may act either by causing clot formation in the cut arteries, or by causing the retraction of their edges. In the latter cla.s.s are included such drugs as _hydrastine_ and _adrenaline_.

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 hydrogen_ on 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 iodine_ in 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+

+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 of _salicylic acid_, 5 per cent. to 50 per cent., depending upon 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+

+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:

_Sulphur_ in 10 per cent. strength, or _ammoniated mercury_ up to 5 per cent., where a paraciticide is indicated.

_Balsam of Peru_ in 10 per cent. strength for the stimulation of granulations; or _balsam of Peru_ and _castor oil_, equal parts; also _boric acid_, or _ichthyol_ for their antiseptic properties.

Ten per cent. _mercurial_, for syphilitic cases.

_La.s.sar'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 occurred the granulations are apt to become exuberant with little tendency to cicatrization.

The ointment which has given the best results is _scarlet 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 should also 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:

Strength

Grains. Percent.

Scarlet red (medicinal Biebrich) 15 1 ungt. acidi borici q.s., ad. 3 ounces.

Scarlet red (medicinal Biebrich) 45 3 ungt.zinci oxidi q.s., ad. 3 ounces.

Scarlet red (medicinal Biebrich) 75 5 balsam Peru, 75 minims.

Petrolati q.s., ad. 3 ounces.

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 a.s.sociated 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+

+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 pa.s.sage of the blood.