40 SURGICAL TECHNIC
it is safest, not to apply any suture nor to insert any drainage, but to
leave the margins of the wound wide open, and to pack the whole cavity
of the wound with gauze (tamponing). By this procedure, the most
rapid absorption of the secretions is procured. In spite of the tamponing,
healing may still take place by primary intention, if, after the course of
two or three days, when the gauze has been removed, the wound appears
to be covered with good granulations. It can then be closed in its
whole extent by deep and superficial sutures (secondary sutures). If, on
the removal of the tampon, a bad condition of the wound, with profuse sup-
puration, is found, the surgeon has to dispense with the suture and allow
the wound to heal by means of granulation and continued tamponing. For
tamponing, especially if the gauze is to remain in position for some time,
iodoform gauze is almost universally preferred. In the case of very large
cavities, too large quantities of the gauze might occasionally produce symp-
toms of poisoning. Under such circumstances it is advisable to use either
very weak iodoform gauze or sterilized gauze for the upper layers of the
tampon ; or else the walls of the cavity are covered with a single or a
double layer of iodoform gauze ; into the remaining part of the cavity steril-
ized gauze is packed. This is removed layer by layer, and thus the cavity
gradually decreases in size {MicuHcs).
But if it becomes necessary to remove very infectious secretions of the
wound, permanent hnniersion and irrigation (see below) often render better
services than tamponing and drainage.
DRESSINGS OF THE WOUND
These have to fulfil the following indications : —
1. They are intended to protect the wound from external injurious
influences, especially from bacteria of putrefaction entering the same.
Hence they must cover the whole region of the wound liberally, must fit
well everywhere, and must hug the surface closely along the margins of the
wound (cover dressings, protective dressings).
2. They must readily absorb the secretions (blood, serum, pus) that exude
from the wound, and must allow them to evaporate rapidly (dressings for
drying the wound).
3. They must prevent the decomposition (putrefaction) of the secretions
(antiseptic dressings, Lister).
The materials for dressings that are to cover the wound : —
I. Must be absolutely pure (aseptic).
THE TREATMENT OF WOUNDS 41
2. Must contain the agents that destroy the germs of putrefaction
(antiseptics).
3. Must be soft and elastic, so that, under moderate pressure, they can
be well fitted to the surface of the body.
4. Must readily absorb fluids of all kinds — must possess great ab-
sorptive capacity.
5. Must be freely pervious to air, in order that the absorbed fluids may
evaporate rapidly and combine with the oxygen of the air.
Materials most frequently in use are the following : —
1. Gauze (muslin for dressings), a loosely woven cotton cloth that has
been rendered hygroscopic (that is, all oily substances have been removed
from it) by boiling in a solution of caustic soda. It is used : —
(a) For the immediate covering of the wound, either in layers, folded
repeatedly smoothly upon one another, as a compress {Lister), or in pieces
loosely and carelessly folded, as "/^n/^//" ^rt?/^^ (loose or lost ga.uze) {vo7i
Volkmanfi).
ib) Made into sacks of different sizes, filled with other materials for
dressings (peat, moss, sawdust, cellulose, etc.), and laid as a cushion or 3. pad
over the few layers of gauze directly over the wound.
ic) Cut into bandages from 6 to 12 centimeters wide, which, sterilized or
dipped into an antiseptic fluid (carbolized, sublimated water), serve for
fastening the protective dressings.
2. Cotton, {a) Hygroscopic ch.3ir-g\e-cotton {zuound cotton, — Bruns), from
which the oil has been extracted by means of a caustic soda solution, absorbs
water rapidly. Hence, in the form of tampons or gauze balls that are to be
used but once, it is very suitable for washing soiled parts of the body and
for packing secreting surfaces (axilla, etc.); but it should not be applied
directly upon the wound itself, because with the admixture of the secretions
a hard, compact, and impermeable layer or crust is formed. Hence, it is used
only for the second layer of dressings over the gauze (the layer should be
somewhat thick), and is restricted to smaller wounds in which there is but
little secretion. In larger wounds, the dressings must be changed oftener,
because the cotton, once saturated with pus, etc., becomes hard and is no
longer absorbent. It is, therefore, not especially suitable for permanent
dressings. For these, cushioned dressings are preferable.
{b) The common non-absorbent cotton is used for upholstering splints,
and especially, in the form of cotton bandages from 10 to 15 centimeters
wide, for padding and covering the margins of the dressings, since cotton,
42 SURGICAL TECHXIC
as we know, is the best filter for the germs of infection suspended in
the air.
3. Lint, a cotton tissue with a rough surface, similar to parchend, is
mostly employed for covering small wounds, especially after previous satu-
ration with a hot boric solution {boj'utcd lint). It is frequently used as a
means of applying salves.
To fill the above-mentioned gauze bags for cushioned dressings, the follow-
ing more or less hygroscopic materials are used : —
1 . Peat coarsely powdered, as peat mull i^Neiibe}-). The light brown vari-
ety (peat moss) absorbs very well (nine times its weight), if somewhat mois-
tened before application ; black peat absorbs less, but possesses antiseptic
qualities, owing to the humic acid it contains.
2. Peat moss (sphagnum). This can be found everywhere in forests and
bogs ; it can easily be made aseptic by washing and subsequent sterilization.
It is very compressible, an excellent absorbent, and cleaner than peat turf.
The needles of spJiagninn are finer and absorb better.
3. Sawdust, wood wool, and cellulose. These are good materials for
dressings, because they are all elastic, absorb fairly well and rapidly, are
easily rendered aseptic by the different methods of sterilization, and are
not expensive.
Sawdust {Porter) can be had everywhere. The dust of poplar absorbs
best of all ; that of fir has also antiseptic qualities. Wood wool and celhilose
are made in factories, and can be had reasonably cheap. The latter are
especially suitable for artificial sponges to be used in operations in the place
of sea sponges, and for filling the pads of splints. Cellulose cotton made of
fir wood fibre is also manufactured in sheets, is very soft, and a rapid
absorbent.
Pine wool, oakum, jute (Araucan hemp), flax, blotting paper, sand, and
ashes are less generally used, partly because they are not soft enough, partly
because they are not sufficiently absorbent.
It may be stated here that the power of absorption of all of these sub-
stances may be considerably increased by the addition of agents that quickly
absorb water, such as cJiloride of sodium, glycerine, etc. They also absorb
more actively if they are previously moistened before applying them.
Owing to the manufacture of these cushioned dressings on a large scale,
their use has been rendered so convenient that they can be used now almost
everywhere. Leisrink and Hagedorn had sphagnum pasteboard manufac-
tured, by strong compression, in sheets of various sizes. These are very
THE TREATMENT OF WOUNDS
43
&^
50 Cu
t.
clean for usage, and need only to be wrapped in gauze to furnish an
excellent sphagnum pad. They can also be purchased already sewed up in
gauze coverings. They occupy very little space, but swell up very con-
siderably when moistened. Just as useful are compressed pine wool and
wood cotton {wood cotton sheets — '' Holzzvattetafeln''' ).
Formerly many various sizes were mentioned for the pads of very large
dressings; for instance, pads — large, 50-70 centimeters square (Fig. 38);
small, 5-10 centimeters square. It is sim-
pler and more practical, however, even in
large wounds, to apply several smaller
pads. It is necessary, therefore, to keep
on hand only about two or three sizes — 5,
10, 30 square centimeters.
Pads 50 centimeters long and 15 centi-
meters wide are suitable for padding the
splints.
Before applying these pads, their con-
tents are so dfsplaced by shaking that they
apply themselves well to all the irregular
surfaces of the region of the wound, so as
to exert a uniform pressure upon the whole
wound, and also that the principal mass
comes to lie on the most dependent part
of the wound — for instance, upon the
back, in dressings of the breast and the
region of the axilla. By turning over
the edges — for instance, in the case of amputation stumps — the surgeon
should attempt to exclude the wound completely by the dressing.
First of all, the pad is wrapped with a gauze bandage in such a way that
it applies itself uniformly and firmly to the portion of the body ; over this,
another layer of cotton may be applied, and the whole then fastened with
a cambric or gauze bandage.
All cavities and lacunae — for instance, the axillary region — are care-
fully packed with cotton or " kriill " (loose) gauze before the bandage is
applied.
Finally, in cases where the operation has been performed on the ex-
tremities under elastic constriction, an elastic bandage of thin rubber is
placed over the whole dressing, in order to add to the compression during
the first two or three hours ; and in operations near the anus, such a bandage
Large Dressing Pad
44
SURGICAL TECHXIC
%
.N^^wwm^
El AiIIC
is placed around the marginal portions of the dressings, in order to prevent
the entrance of intestinal secretions into the dressings (Fig. 39).
Waterproof materials are only rarely used in dressing
wounds, since it has been found that they do more harm
than good, preventing the secretions of the wound from
.. _-_ , evaporating. Among these materials is Z/i'/'rr'x protective
rliiL—J-lfliS silk {protective taffeta), which he used directly on the
wound, to protect it from the irritating effect of carbolic
acid, etc. If the materials for dressings possess sufficient
power of absorption, this protection is just as little needed
as the spun glass zuool, recommended for the same purpose
by ScJiede.
The same must be said, also, of the expensive mackin-
tosh which, in the original Lister dressings, was placed
between the seventh and the eighth gauze layer, to pre-
vent any of the secretions of the wound from reaching
the surface of the dressing. If something of this kind is
to be applied, the less expensive glazed paper is preferable.
This can be prepared by the physician himself in the fol-
lowing manner : —
Brush silk paper with linseed varnish to which 3% of
siccative or varnish extract has been added. Hang up the saturated sheets
on threads in an airy room for 48 hours, until they are completely dry. To
render the paper antiseptic, add to the varnish i % of thymol. The var-
nished paper is quite suitable, also, for covering the compresses and keeping
them moist {Priessjiitas compresses, cataplasms); for this purpose, more-
over, parchment paper, oil cloth, and gutta percha may be used.
Stronger waterproof materials, such as cotton cloth saturated with oil or
caoutchouc varnish (for instance, BillrotJis batiste, oil cloth, etc.), are used
to protect the bed linen in changing the dressings, in permanent irrigation,
etc.
The pure caoutchouc materials of raw brown caoutchouc are very suit-
able for covering the operating table, for protecting other portions of the
body during operations and dressings (see Fig. 21), and for aprons of the
surgeon and his assistants. From the same material the caoutchouc band-
ages 5-10 centimeters wide are made.
Bandages serve to keep in contact with the surface and hold in position
the dressings and splints, to cover, support, and fix in an immovable posi-
tion injured portions of the body. They are manufactured: —
Ba.nd.\ge
THE TREATMENT OF WOUNDS 45
(a) Of gauze. These apply themselves well if previously moistened.
When they have been saturated with starch {organtine) they become agglu-
tinated in drying, so that the dressings can be no longer displaced {aggluti-
native bandages). They are chiefly used for fastening antiseptic dressings
and for plaster of paris dressings.
{b) Of cambric. These are very soft and phable, and can be fitted to
the surface of the body as well as flannel bandages ; they are less expensive
than flannel, are very durable, and can be easily washed. They are espe-
cially suitable for applying difficult dressings and for the fixation of splints.
{c) Of cotton. These are very soft and compressible, and are, therefore,
quite suitable for the first layer in antiseptic wound dressings and for
padding splints and plaster of paris dressings.
{d) Of linen, preferably torn or cut in the direction of the threads from
old, soft linen that has been often washed. Bandages of nezv linen cannot
be well applied, because they are too stiff.
(£-) Flannel. These are soft and elastic, and can be well applied ; they
are especially suitable for bandaging entire limbs and for surface layers in
starch and plaster of paris dressings.
(/) Of shirting or stouts. These are cheaper than linen, and are well
adapted to starch dressings.
{g) Of tricot (" tricot schlancJi "). These are highly elastic and pliable, and
are especially suitable as a substitute for cambric bandages.
(//) Of caoutchouc, either pure, as brown caoutchouc bandages, or of
materials woven with caoutchouc threads. These, aside from their great
elasticity, have the advantage of allowing the air to pass through, so that
the moisture and the heat of the skin, so annoying in using pure rubber
bandages, are avoided.
They are used : —
1. For bandaging limbs in procuring local anasmia.
2. As bandages over the whole dressings of the wound after bloodless
operations on the extremities, in order to increase the compression during
the first two hours until the danger of after-bleeding is passed.
3. For compressing the margins of the dressings (Fig. 40), in order that
no air may penetrate the protective layer of the dressings ; for instance,
during the movements of the breast in breathing, or of the abdomen ; or in
order that no faecal matter may enter it, as after operations on the perineum.
In applying aseptic or antiseptic dressings, great care should be taken
that the materials for dressing safely cover the region of the wound and its
7ieigJibjrJiood, in order that no infection may occur after the dressing has
46
SURGICAL TECHNIC
been applied by the entrance of microbes between the dressing and the
surface of the body. For this reason, dressings of the present day, com-
pared with those of former septic times,
are very large and extensive. In opera-
tion wounds — for instance, on the neck
— the turns of the bandage, for a firm
support and for a good adaptation of the
dressings, must be carried, not only around
the head, but also around the chest (Fig.
40). In wounds of the thigh, the region
of the pelvis must at the same time be
included by the bandage (Fig. 41).
Whether in this case the rules of the
former art of bandaging are minutely fol-
lowed is of little consequence, with the
soft and elastic materials for dressings of
the present time (agglutinative dressings),
provided the dressings are kept in contact
zuitk the surface and are firmly applied.
As mentioned above, the very first condition for a good dressing is its
sterility — namely, that it be absolutely free front all living germs.
Although this sterilized dressing can be easily obtained in larger institu-
tions having steam sterilizers, it is difficult, and perhaps inconvenient, for
Fig. 40. Antiseptic Dressing of Large
Lateral Wounds on the Xeck
Fig. 41. Antiseptic Cushioned Dressing of Stump after Amputation
the practising physician to procure for himself the necessary smaller quan-
tities in a perfectly sterile condition. For when the materials for dressing
from larger sterilized packages are not entirely used, the rest no longer
remains absolutely aseptic.
THE TREATMENT OF WOUNDS 47
Very useful in practice, therefore, are the dressing boxes mentioned by
DiiJiTsseji — boxes of tin containing everything needed for the dressings
of a certain portion of the body, in simple, sterilized antiseptic materials,
and in quantities no greater than will be needful in a single operation.
The boxes contain, according "to the size of the dressings to be made,
various quantities of sterilized iodoform gauze, absorbent cotton, cambric
and starch bandages. These boxes containing a few grams of iodoform
powder, in addition, can be purchased.
By using these dressing boxes, which are prepared in factories, the
physician, apart from the inconvenience of personally sterilizing the materials,
has the best guarantee of the aseptic condition of each dressing.
CHANGING THE DRESSINGS
The dressings of purely aseptic wounds should, if possible, remain in
position until the wound is completely healed ; or, at least, they should be
changed as rarely as possible {permanent dressings).
But in order not to miss the right period for changing the dressings, the
physician must frequently examine and inspect them, especially at their
most dependent portion. Moreover, he must take the temperature of the
body by means of a thermometer, and observe carefully the general con-
dition of the patient.
When secretions from the wound penetrate the dressings and reach their
outer surface, they begin at once, through the influence of the air, to decom-
pose ; and this decomposition spreads rapidly, through the layers of the
dressings, to the wound.
To prevent this, it is above all necessary that these secretion stains
should dry up rapidly. If this occurs, the development of the germs of
infection, which thrive especially in a moist nutritive soil, is most effectively
prevented. If the drying up does not proceed rapidly enough (for instance,
in larger hemorrhages), the uppermost layers of the dressings, at the place
where the secretions made their appearance, must be disinfected at once
with a sublimate solution or with iodoform powder, and then must be
covered with an absorbent pad extending far beyond the stain. (The best
method to proceed in such cases is to dust the moist surface freely with
boro-salicylic powder and apply a thick cushion of absorbent cotton.)
If the stain of secretion is larger than the hand, it is better to remove the
uppermost layers of the dressings down to the gauze that lies directly upon
the wound, and to substitute for them new, sterile, dry dressings (pad, cotton).
48 SURGICAL TECHNIC
A change of the whole dressing becomes necessary : —
1. If a violent pain in the wound sets in.
2. If there is fever with such disturbances of the general condition of
the patient that sepsis of the wound appears probable (septic fever). But
if, notwithstanding an increased temperature (up to about 102° Fhr.), the
general condition remains good, the skin and the tongue moist (aseptic
fever), then sepsis of the wound need not be apprehended.
3. If an unpleasant odor emanates from the dressing.
4. If drains have been inserted in the wound. Then the dressings
must be changed, after a few days, in order that the drainage tubes may be
removed. If the same remain in position longer than necessary, they some-
times produce a more copious secretion of the wound, and the canals created
by them close only very slowly.
A change of dressings must be made as rapidly as possible. It is, there-
fore, necessary to have in readiness everything that might be required in
making the change.
Before removing the dressings, the patient is placed so that a new dress-
ing can be applied conveniently. The bed is protected from being soiled
and saturated by a rubber sheet, placed under the patient.
If the uppermost layers of the dressings consisted of agglutinative
bandages, they must be previously moistened, if tearing off the agglutinated
turns should be painful to
the patient; cambric band-
ages can be unrolled more
easily. But if it is not nec-
essary to be economical with
the dressings, they may be
Fig. 42. Dressing Scissors '^^^ removed most rapidly -by
being cut lengthwise with a
large pair of strong scissors (dressing scissors — Fig. 42). Care must be
taken that the scissors do not grasp the layer of cotton that may have been
placed under the bandages ; for cotton is hard to cut, and is more easily torn
apart with the fingers.
If the wound is found to be aseptic and dry, it is entirely unnecessary to
irrigate it. The surroundings alone are cleansed by wiping off with tampons
or wads of cotton, and then a new dressing is rapidly applied.
If rubber drainage tubes have been inserted, they are extracted, cleansed
from blood clots or pus, and placed again in position only if, under pressure,
secretions are still discharged from the depth of the wound.
THE TREATMENT OF WOUNDS
49
If the wound in healing shows superficial granulations, a little borated
lint or a piece of gauze covered with boric vaseline is applied to it.
Cicatrization proceeds still more rapidly under a very light dusting with
iodoform powder. Prolific hypertrophic granulations that project beyond
the surrounding margins of the skin, and thereby prevent cicatrization, are
dealt with by light cauterization with a lunar caustic pencil or by the appli-
cation of a 2%-3% salve of zinc sulphate (zincum sulphuricum). The
cauterization is perfectly painless if the physician is careful not to cauter-
ize the tender epithelial margin. Flaccid, glassy, hypertrophic granulations
are best removed with the sharp spoon ; afterward the wound is dusted
with iodoform. (It has been found that dusting such surfaces with aristol
or dermatol is more conducive to improve the granulating process and epi-
dermization than the use of iodoform.) The surgeon may proceed in a
similar manner if the formation of granulation is scanty and the wound
does not heal. In such a case, the surface of the wound may also be
painted with a tincture of iodine or with some irritating salve. (Balsam
of Peru is one of the most potent tissue stimulants known.)
If eczema is foimd in the neighborhood of the wound, the irritated place
is thickly painted with salicylic glycerine salve, boric vaseline, lanolin,
or Lassars paste (zinc, oxydat., amyl. tritic. aa. lo parts ; acid, salicyl.,
I part ; vaseline, 20 parts).
If the healing has not taken place by first intention, an antiseptic dress-
ing is again applied, and is as often changed as the secretion of the wound
demands.
But if the wound has become septic, if inflammation, suppuration, lym-
phangitis, phlegmon, or erysipelas has set in, all sutures must be removed
immediately; the wound must be opened sufficiently, and must be thoroughly
disinfected and drained as described further below (see secondary antisepsis).
In applying the first dressings after the operation, or in changing larger
dressings,
THE POSITION OF THE PATIENT
is of especial importance.
The patient must be placed in such a position that the portion of the
body to be dressed is freely accessible from all sides, and that the whole
body may retain this position unchanged while the dressings are in position.
For the support of the body serves partly the operating table or the bed,
partly the adjustable telescopic hip rest (Fig. 43). For adults, this support
should be 20 centimeters in height, and in many cases two of them are
E
so
SURGICAL TECHNIC
Fig. 43. McBurney's Adjust
ABLE Telescopic Hip Rest
required. The hands of the assistants or of the nurses hold the body firmly
in the position indicated. In many cases of dressings on the leg, good use
can be made also of a support for the heels (see
N below).
:" ""[ Dressings on the head are best applied when
the patient is sitting or is held in a sitting posi-
tion ; likewise, in the case of dressings on the
thorax ; if the patient is still under anaesthesia,
he is placed across the operating table, while his
arms are moderately drawn aside. In dressing
the region of the pelvis, a pelvic support is
placed under the sacral region, or the patient is
placed in a lateral position on two supports. In abdominal dressings (after
laparotomies), two supports for the back are very convenient. In dressing
the leg, the pelvic support is not placed transversely, but parallel to the axis