Surgery, with Special Reference to Podiatry

by Maximilian Stern; Edward Adams

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.