+DRESSINGS AND BANDAGING; SOLUTIONS AND OINTMENTS; SKIN GRAFTING+
+DRESSINGS+
+Dressings.+ These may be either dry or wet.
_Dry dressings_ consist of gauze and bandage or of cotton and
collodion (the cocoon dressing.)
The most convenient form in which sterile gauze can be obtained is in
small squares in individual envelopes. Large packages are contaminated
with the first opening and are inconvenient.
The cocoon dressing is occlusive and should never be applied over an
infected area. It is applicable to sensitive areas for protection, and
to operated areas not liable to infection.
Protective varnishes, such as collodion, compound tincture of benzoin,
or pure ichthyol, are useful where little protection is indicated.
_Wet dressings._ Two distinct therapeutic actions may be derived from
the wet compress, depending upon whether or not an impervious covering
is employed. These actions are _antiphlogistic_ and _hyperemic_, and
these in turn may be either _antiseptic_ or _astringent_. The wet
dressing, without a covering, is cleansing and heat reducing, because
of evaporation. There should be frequent replenishment of the solution
in the treatment of any infected wound or where it is desirable to
reduce inflammation.
A wet dressing with an impervious covering is contraindicated in the
presence of pus, the warmth and moisture of such a dressing being
congenial to the growth and to the multiplication of bacteria.
It is evident, therefore, that a wet dressing with an impervious
covering can safely be employed only in conditions where the skin is
unbroken, such as sprains and bruises.
The two general therapeutic actions, aside from those of causing
hyperemia, are antiseptic and astringent. For the relief of pain and
for the reduction of inflammation, wet dressings are the most
effective form of treatment because (1) they are aseptic; (2) they
permit free drainage; (3) no new granulations are disturbed in
changing the dressing.
A great many different solutions are used and among these are:
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:
chlorinated lime (bleaching powder) 200 gm.
sodium carbonate,dry 100 gm.
sodium bicarbonate 80 gm.
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.)
+DUSTING POWDERS+
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_, or _aristol_, is a splendid antiseptic powder and
enjoys the advantage over iodoform of being inodorous.
_Iodoform_ should only be used in tubercular conditions.
_Dermatol_, or _bismuth subgallate_, combines the astringent and
mildly antiseptic qualities of bismuth and gallic acid.
_Boric acid_ is mildly antiseptic.
_Calomel_ should only be used in syphilitic conditions.
_Zinc oxide_ and _alum_ are 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 nitrate_ is employed for its astringent action, as are also
the _copper_ and _zinc 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 stronger _lotio alba_ of 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+
+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 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.
_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 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 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+
+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 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
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 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 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 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 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.
+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
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 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.
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.
+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 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 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 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 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 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
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.