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Because most operations today are performed in hospitals, it is well for family members to know how best to aid the recovery of their convalescing relatives. Undue visiting should be discouraged. The frequent recital of a person’ s own operation and details of hospitalization can help to depress and confuse the individual recovering from surgery. Visiting just to “chit chat” in the hospital should be kept to a minimum. Well wishers should either send cards or reserve their condolences for later. A devoted family member or trained nurse, however, can be of incalculable value to the convalescing surgical patient.

Immediately after major surgery the incision should be cooled with an ice pack applied over the dressing. This will reduce swelling (edema fluid), lessen the likelihood of bleeding, and modify impressively the pain responses. Avoid excessive movement of the involved area, while maintaining activity in remote portions of the body. And especially encourage deep breathing. This will aid the rapid emergence from anesthesia, while minimizing the sensation of severe pain.

After the initial recovery phase is ended, moist warm compresses can be applied over most incisions, except in areas where the blood supply is compromised or at the distal extremities. In the latter case cold packs may be used. Over the chest and abdomen, however, frequent applications of moist warm packs, such as fomentations or electric heating devices will significantly reduce the pain, while promoting rapid healing of the involved area.

At this stage the healing processes will occur more rapidly in the presence of warmth, since all enzyme reactions as well as the growth of new cells are speeded up by mild heat. Usually the moist hot pack can be applied every three to four hours, enabling the convalescing patient to relax in between, gaining the necessary rest that promotes recovery. From the very first, the incision should be protected from undue moisture and kept clean and dry. Daily changes of the sterile gauze dressing are helpful in allowing air to reach the incision and dry the sutured area.

Adequate fluid intake is important. After abdominal surgery intravenous feedings are often used until the intestinal tone returns. This manifests itself by the passage of gas, and a sensation of hunger. One can hear “bowel sounds” when listening to the abdomen with a stethoscope. At this stage, the patient may be given sips of water or ice chips. If these create no problem, clear liquids such as herb teas, apple juice, vegetable jello, grape juice, and vegetable broth may be added.

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The removal of a tissue for accurate pathologic diagnosis is called biopsy. If the lesion is large and only a small part is to be removed, the surgery is called an incisional biopsy. Usually a small portion of normal adjacent skin is excised with the lump under question. When it is possible to completely remove the growth and obtain a margin of normal tissue around it, the procedure is termed an excisional biopsy. These are very useful procedures, not only for the diagnosis and treatment of blemishes and abnormal growths of the skin, but also for lumps beneath the skin in accessible organs, such as the breast.

A breast biopsy can often be performed without general anesthesia or hospitalization when the surgical skills are present and the necessity for tissue diagnosis exists. More commonly, skin biopsies are used to determine the presence or absence of cancer and to excise unsightly or irritating growths that have developed in areas amenable to their removal.

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One of the oldest forms of medical treatment is described in Genesis 2:18, 21-23, where the Creator Himself “caused a deep sleep” to come upon Adam while He took out the rib, closed up the incision, and made a “help meet for him.” Relief of pain is intimately associated with the rendering of needful medical care. This is one of the physician’s cardinal responsibilities. For certain patients, some forms of severe pain may be life threatening. However, in the case of most effective pain relieving medications, addiction can occur, with distortion of mental imagery to the point of serious impairment. Thus, it is wise to look for the simplest methods of relieving pain when attempting to perform surgery.

Probably the oldest form of pain relief is refrigeration anesthesia. Extremities can be rendered pain free with ice packs. This is particularly valuable in the case of vascular disease where cardiac and circulatory impairment makes general anesthesia risky. During the World War II, army medics discovered that troops suffering from frostbite might save their limbs if the extremity remained frozen until medical care could be secured. This observation influenced all currently accepted first aid for frostbite used in our country.

In order to properly administer refrigeration anesthesia, the extremity needs to be cooled to the point of numbness, while keeping the remainder of the body warm to avoid a general drop in temperature, chilling, or agitation. Ice packs or snow can be used to progressively cool an extremity, either a hand or foot. If the surgery is to be localized to the arm or leg, place the pack just above the site of amputation. This reduces blood loss and allows for a careful, meticulous dissection of the tissue. Broken bones can be set with refrigeration. In the case of a simple fracture of the hand or wrist, immerse the extremity in ice water for one-half hour or more. This will allow manipulation and bone setting to be done quite painlessly.

Refrigeration can also be used topically in the removal of warts, moles, and other skin lesions. Dry ice or liquid nitrogen can be applied with a cotton applicator to freeze a small area and render it numb to pin prick.

A second method of anesthesia is the application of gradual pressure on a nerve. The ulnar nerve at the elbow (funny bone) is quite amenable to pressure. Quite often in certain positions a foot or a hand has been known to “go to sleep” due to stretching or pressure on an affected nerve. Knowledge of neuroanatomy can utilize this principle favorably for surgery to an extremity.

Counterirritation can also be applied with electric stimulation near the point of incision. This can utilize DC current, but it is more effective with a pulsed generator, such as rehabilitation centers employ in treatment of chronic pain. Desensitization can be obtained with liniments and ointments, mustard packs or plasters. Even animal surgery has been performed using counterirritation, e.g., the “twitch” on the nose of horses.

Finally, it is helpful to understand some of the common injectable anesthetics that are used locally for the relief of pain. These are used both in dental and surgical care. But they have some side effects and potential allergic reactions. Injectable narcotics should always be avoided, as they leave behind serious effects on the brain. They are not only difficult to metabolize, but because of their tendency to produce euphoria can become rapidly addicting.

On rare occasions for major procedures, general anesthesia may be necessary. The gaseous agent used in these cases should be that which is most rapidly metabolized and least toxic to the system. Nitrous oxide and oxygen are commonly employed together to relieve mild pain. Although ether is quite flammable, it still remains the safest form of general anesthesia, due to its rapid clearing from the blood by the way of the lungs and relatively low toxicity to the liver and other organs. Open drop techniques in a well ventilated area can be used, but for safety reasons general anesthesia ideally should be performed in a hospital. Newer anesthetic agents (Halothane, Ethrane, etc.), although more likely to cause toxicity, are less dangerous to the heart and usually nonflammable. Regional blocks, local nerve blocks, and spinal anesthesia have their places in hospital settings but it is beyond the scope of this book to detail their applications.

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Considerable practice is required to suture incisions and lacerations quickly and accurately. Yet these skills are not beyond the reach of the average layman gifted with manual dexterity or an interest in mastering the art. If possible, practice your suturing techniques on a piece of sponge rubber, upholstery, or even a pillow. Some surgeons become skilled in knot tying, practicing on door handles or in the automobile while traveling. The accompanying diagrams, located on pages 178 to 189, help demonstrate the principles of the three basic methods of surgical knot tying. The one described as an “instrument tie” utilizes a hemostat or needle holder, while the others require only skillful fingers for proper use. I would suggest that a novice begin with the two-handed tie and instrument tie, adding more complex forms as skill is gained.

Avoid tying the sutures so tightly that insufficient blood flow to the skin edges results. This would cause delayed and incomplete healing of the wound. “Approximate, don’t strangulate” is the watch word for closure of lacerations with sutures. As described in the following chapter, there are certain injuries that are never sutured. Human bites, animal bites, and lacerations opened longer than 12 hours, or those grossly contaminated are not sutured, but allowed to granulate and heal by secondary intention.

The placement of sutures and selection of suture material will be described in the following sections, as the various types of lacerations and their special care are considered. In a home-like setting it is possible to make the appropriate needles, like bending a sewing needle, sharpening the point in a chisel fashion to better penetrate the skin. Silk or cotton can be boiled along with the needle, thus sterilizing it for use in suturing. Prepared packages, that come already sterile, are available from suture manufacturing companies and can be obtained in various sizes and needle styles. Remember to consult the suture use manual for aid in selecting the appropriate sutures.

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There are three basic methods by which a wound heals itself. Primary Intention is the usual type of healing when an incision or laceration is closed immediately to allow close adherence of the opposing skin edges and subcutaneous layers. This permits healing from side to side with the least amount of scarring and pain. The rate of healing of our skin depends on its blood supply and the presence or absence of pressure, tension, and infection. The facial skin, with its rich blood supply, can heal in 3-5 days, while a thickened area of skin with less nutritive potential, such as the back or feet, may require two weeks or more. If sutures are placed, it is important to know how long healing will require to avoid too early removal and wound separation.

Secondary healing of a wound occurs when the laceration is too large to be closed or is infected and must be left open. A general principle of laceration treatment is this. A wound that has been open more than 8-12 hours is never sutured, since infection may already have developed. In such case, granulation occurs with the formation of a specialized tissue across the wound, and later coverage with new skin. Some deformity and scarring usually occurs. Nevertheless, with the exception of very large ulcers, the skin healing is usually complete. Understandably, this takes longer. Proper care of the wound to prevent or treat infection will serve to hasten the healing process.

The third method involves the initial formation of granulation tissue, then a secondary closure of the wound with sutures. This accelerates the healing in large open lesions and is usually used when a surgical wound, for some reason, separates and must be closed again. Even more scarring takes place as a rule, but the healing is usually complete.

Some essential factors in wound healing are the presence of adequate protein, vitamins, oxygen, and the prevention of infection. It is generally recognized that the normal rate of healing in a perfectly healthy patient is the optimum rate that can be obtained. Wounds do not heal as well in anemic patients. With a normal complement of white blood cells the healing of a sterile wound is not impaired. However, when infection is present delayed healing does occur. Swelling (edema), whether local or general, appears to interfere with the healing process. Older individuals take longer to heal than the young. Endocrine factors, such as the possible deficiency of thyroid or growth hormone, or adrenal dysfunction, may retard or interfere with the healing process.

Local factors are important. According to Van’t Hoff’s law, reactions occur more rapidly when the temperature is increased. Conversely, hypothermia will delay wound healing in most areas, although cold is sometimes used for pain control. The areas of the skin which have the best blood supply, such as the face and neck, normally heal the fastest. Fat persons tend to heal more slowly, and their wounds tend to separate more often than in people of normal weight. Skin sutures are usually left in longer. Cleanly incised wounds will heal more rapidly than irregular jagged lacerations. The presence of a blood clot or hematoma may interfere with proper wound healing by preventing close contact of the walls of the wound, and thus there forms a pocket, called “dead space.” Infected fluids, pus, and foreign bodies will all retard the healing of these wounds.

It is critical to cleanse the wound of all foreign debris, irrigating it thoroughly before any suturing is attempted. Suture material is also importantin the care of wounds. Although stainless steel is the least reactive, it is difficult to handle and remove. The absorption of foreign material, such as gut, silk, cotton, and nylon will occur slowly, in the order that they are here mentioned. Newer sutures of nylon, Dacron, and Teflon last longer and cause less reaction, but are not suitable everywhere. A suture use manual may be consulted to aid in selecting appropriate materials. The suture manufacturer’s suggestion of needle size, type, and techniques should also be consulted.

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