Surgery, with Special Reference to Podiatry Part 28

At present the therapeutic use of the X-ray is rightly falling into the hands of the dermatologist and the medical clinician. In surgery, outside of the conditions mentioned above, its use is limited to lupus, keloid, epithelioma, sarcoma and carcinoma, both before and after operation.

CHAPTER XIX

+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 coc.o.o.n 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 coc.o.o.n 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 b.i.+.c.hloride 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 quant.i.ty 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 _bis.m.u.th subgallate_, combines the astringent and mildly antiseptic qualities of bis.m.u.th 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.