Introduction and concept of surgery.
Hygiene in a surgical hospital. Work of the average personnel in conditions of surgical department.
The organization of work in a clean dressing room. A desmurgy, a dressing material. Typical gauze bandages. Bandages on the head, neck and thorax. Patient's care, has an operation on a head, a neck and thorax.
Patient's care, has an operation on organs of abdominal cavity, a perineum, extremities. Bandages on a stomach, a perineum, extremities.
The History of Development of Surgery
Surgery – it is that part of medicine, which developed extremely unequal in different social-economical period. After the period of ancient significant development in some ancient countries, 2-4 thousand years ago a period of complete degradation occurred in the Middle Ages when the church supreme sharply sloped the development of medicine and surgery. Lastly, from the XIX - XX century and till today we are living in the period of most intensive and swift development of surgery.
We obtain a summary of surgery of the past from archaeological excavations of books, drawings on rocks, washes, antique sculptures and even from popular epic literature and legends. Proverbs, story embellishments. The primitive people laugh with the forces of attire belied in bad and good souls, used simple means of treatment. No doubt the very first medical means were used in cases of traumatic injuries (while hunting, or during the war) and during wounds complications, in cases of blood loss, during birthing and during other diseases.
Due to helplessness of man in relation to the forces of nature, animation and fetishism, sorcery shamanism and which craft acquired wide popularity. All phenomenon of nature (fire, water, air, earth) and all diseases of man (fever, shivering, swelling, convulsions and others) were associated with bad souls from which it was necessary to be delivered, thrown out from the body of the diseased, or deceived (dance with noisy effects, marks, freighting cloths of shamans). Gradually personalities, which had «contact» with these souls, were separated in separate casts of priests and magicians.
An often-similar skilled craftsman empirically was having collected experience of treatment of diseases and having used this experience along with demonology and mystique. Were concentrated in temple, churches, and missionary hospitals. So gradually having been separated to qualitatively different directions in medicine developed: temple medicine, which was more improved and scientific and public medicine, which was primitive and developed empirically with out any pretensions on scientific character of knowledge.
“Surgery” (from Greek “Haira” “ergon”) means “hard work”. This name was invented in ancient times and was used for a contrast of surgery as handcraft – to internal medicine, which was at that, time not sufficiently, studied difficult and clandestine science. Personalities who went through complete preparation in churches or special medical schools worked with internal medicine. Any personality could work with hard work i.e. dressing of wounds, slopping of external blood loss, the setting right of dislocations and treatment of fractures. Often this work was earned out by people who did not understand anything in this context, barbers, miners, bonesetters or wise people of war, magicians.
For a period of many thousand years people with different diseases, which had external science of disease - wounds, trophic ulcers, abscesses, inflammatory diseases of the eye and tumors went to such surgeons. In this way, the circule of pathological conditions with which surgeons worked was very big and the theoretical preparation of these doctors was very low.
On the other hand keeping in mind this sleep all of culture, science and medicine, which was seen in the medal of the century it is also necessary to mar up that for 2-4 thousand years in many countries of the ancient age medicine and surgery was sufficiently developed and well organized.
Notwithstanding the simple idea
about the world (the 4 elements that were worshipped carts, water, air and
fire) was in ancient
In these countries of hot climate and a large number of skin and parasitic diseases and priests of temple medicine justly paid a lot of attention to hygiene, culture of the body, water procedures and physical exercise. The bodies of the dead were often embalmed, therefore doctors of temple medicine has some idea about (lie anatomy and physiology of man, new about the movement of blood in blood vessels and formed inc brighter "Day blood" they named "Night blood".
For the education of doctors and doctors special schools were formed and
The most knowledgeable doctors specialized in internal diseases which treated by herbs, dick, and physical exercises or advises, surgeons did handwork i.e. treated wounds and wounds complications, bloodless, fractures and dislocations, superficially located purulent diseases and tumors. In this way they were differentiated from doctors of internal diseases, which developed so called "the medicine of herbs". Surgeons paid more attention to practical habits and perfection of the decreasing of the feeling of pain in their patients; doctors numbed them by wine, opium, and infusion of Mandragora. For the carrying out of surgical intervention the use bronze knives and sufficiently large set of other surgical instruments.
In some countries strict laws were formed which undoubtedly curved the
broad development of surgery. We found the most complete idea about medicine
and the doctors of this age from the so called code of laws of the king Hamurat
It is necessary to note that to the medicine of the knife and to surgical operations only those personalities were allowed which consolidated three-times and successfully treated their patients. After the successful operative treatment respected person of the knife were allowed to lake a payment of honour which, depending upon the social level and level of prosperity of the patient appeared in the form of a heaps, money, coined from expensive metals, or else on the form of a mould of that organs which was successfully treated.
At the same time when the medicine of the knife was used non-qualificationally, at the negative ending of a surgical treatment, the doctors was condemned and tritely fined the seeping out of one or two eyes, the cutting of fingers, wrist or full hand.
Touching an honourable and very high social position of doctors in society, Asyrian laws as said that a doctor must find any possibility for the perfection of personal knowledge, be polite, save doctoral privacy, not trouble patients by insubstantial convectors and talk about real things. These wise advises may be used by any modern doctor.
The highest development of
medicine and particularly was attained in ancient
Progress of medicine was seen also in ancient China not any less than in India. The medicine of the knife was counted as the most responsible method of treatment, to which were emitted doctors which treated patients of "Knife cuts" not less than 3 times successfully. Surgery in China was highly valued and characterized as "a precious gift of the skies and on external source of glory". Chinese surgeon Hua-tu, Ben-cyao used shins from bamboo for the fixation of fractures, studied anatomy on dead bodies, carried out laparotomy and Caesarean section, used a wide assortment of medicinal herbs and acupuncture.
In ancient China sciences such as "study of the windows of the human bodies", "study of the juices of the organism"(urine, blood and bile) was learned. Young doctors in those far away times gave wise advise which have not loosed their actuality even today. For example: who hides diseases from a doctor is cheating himself, or "Do not cure only the head if head is aching, and only leg if leg is paining", or doctor must treat only that, which can be treated, if the disease is uncurable then try to make ease his suffering.
Unfortunately, we should note that in some countries, where medicine is a source of money for the doctor even patients, who have not undergone operation are given treatment which costs them very much and which is not even helpful for patient, but is a source of money for the doctor.
A particularly agree heritage has been left by ancient Greek and Roman doctors. In these developed countries, books, collections, which were written, by Hypocrites and Scells, Galeni became source of medicine knowledge and influenced medicine in all the nations of Europe till mid-century.
Hippocrates was (400 years B.C.) intelligent general practitioners talented surgeon and instructor. Having attentively collected anamnesis from his patients, he accurately wrote clinical symptoms of diseases, studied Anatomy on dead bodies. Using different surgical methods of treatment he devoted a lot of attention to psychotherapy, advising physical exercise and natural methods of treatment (sun-shine, air, water). The "Oath of Hippocratic" became the most famous, which is given to young doctors who are starting their professional additives.
The blossoming of ancient Rome determined the displacement of the center of medicine from Greece to Rome, although Roman doctors were students of Hippocratic. The most famous representative of Roman medicine was K. Scellse (I century B.C.) and also Cl. Galen (I century B.C.). The compositions of Scellse and treaties of Galen are the basic guiding compositions for doctors of west Europe till XV - XVII century.
- Scellse was the first to use ligature for dressing of wounded blood flow, used as tubes for the raining of wounds. In this composition, a part from this, we find the first coveting wilh accuracy of the clinical period of full-blown cancer of the lower lip.
- Cl. Galen, in the period of his times was a doctor of gladiators, saw all processes which happened at the site of wound, tried to sow wounds by silk, used bronze tubes, for the draining of wounds he thought that pus is wounds is a necessary composite part of the process of healing, having misplaced complications of wounds with the process of regeneration (healing through pus formation). Having studied the anatomy and physiology of man he some how thought that the center of blood circulation was not the heart but the liver. Also he was very interested in the search of the medicinal herbs and preparation of target medicines and "highly effective means of treatment".
- After the introduction of Roman Empire many difficulties of surgery were removed and forgotten. Surgery met with a strong opposition from the church, cult-followers and religious fanatics, who restricted the dissection of dead bodies, restricted the carrying out of any operations which lead to blood loss and attempts to study anatomy on dead bodies lead to causation of heresy and threatened the scientist with fire and inquisition. The Church Supreme in the century of the middle ages became practically insubduable obstacles for the development of surgery which became all the more simpler and transformed into handwork.
At the same time many daredevils and talented doctors continued to study and to develop surgery, having overcome religious superstitions and having achieved specific success. To these benevolent doctors can be included the Arabian doctor Abu-Iban-Sina (Avicenne), who left more than 100 scientific works on different questions of medicine and surgery; A.Vasilie - the founder of normal anatomy, V.Garvey who discovered blood circulation in man and also Hy-de-Sholiak, Ambrose Pare, Bruno de Longenbourgh, Paracells and a number of other surgeons. A complete era in the history of surgery was made by N.I.Pirogov, who wasn’t only a wonderful anatomist, a brilliant surgeon but also an alienated scientist, innovator and government official.
Almost up to the XVIII century a progress of surgery was not much, this is connected in some or the other way to the difficult conditions of surgeons.
A revolution took place in the XVIII century when the French surgeon La Franchic was the first to be allied to give a lecture on surgery in the medical faculty of Sorbonna's University (1719).
In this way not wish standing the fact that surgical measures are related to the most ancient habits of medical profession. Surgeons for a long time did not find recognition in official medicine and wasn’t even permitted called doctors. It is necessary also to note that even when surgery was at last knowledge as an official medical speciality it was not able to be essentially perfected up to that point when scientists of the whole world found a way for the overcoming of 3 main obstacles:
1. Shock, which was often seen at the time of operation due to the absence of methods of anesthesia.
2. Infections, which complicated all surgical interventions due to the fact that doctors did not have means of asepsis and antisepsis.
3. Blood loss and its consequences with which doctors could not fight because the problem of isohemagglutination and the study of blood groups were not yet decided.
Further we agree with you in the fat all these important obstacles for the development of surgery found their scientific substitution only at the end of XIX century AD. It is true that many questions of surgery are still not clear and demand study. But the basic means of future development of surgery have already been determined and actively entreated in life.
Surgeons of Ukraine having continued the glorious traditions of N.I. Pirogov, V.A. Karavaev, S.M. Colomnin, M.B. Sclifisofsky, O.S. Yacenko, V.F. Grube and other famous surgeons who worked in Ukraine, have found large successes.
The names of M.M.Volkovich, P.M.Trichleva and K.M.Sapezhka were unbreakable connected with world's leading surgeons. These connections were made by N.I. Pirogov in large measures as his own works and also y direct contact in create activities if Ukrainian surgeons "Pirogov connected University - academicals surgery to official"- wrote V.A.Oppel.
A.I.Bogaevsky, M.P.Trinkler, O.A.Yucevich, M.M.Volkovich, C.M.Sapezhka, B.G.Kozlovsky, L.I.Malinovsky and others showed the successful developments of abdominal surgery in significant measures.
Surgeons of Ukraine have always taken an active part in the work of organs of health preservation, in the activities of surgical organisations for the propaganda of medical knowledge admits the population have been the guides of a number of important governmental measures directed towards the betterment of the medical help to the population. Especially surgeons were the initiators of formation of the system of anticancer and anti-tuberculosis institutions the republic, the clear organization of ambulance and round the clock help. They founded the dispanserization of the population - one of the basic stars of medical prophylactics: they founded famous surgical schools. In the foundation of these schools a major role have been played by V.M.Shamov and his schools founded the scientific solution of the basic problems of blood transfusion, penetration of the method of blood transfusion in practice, the solution of important problems of neurosurgery, abdominal surgery, endocrinology, transplantation of tissues of malignant formations, war-field surgery. To him have been accredited more than 100 large works, some monographs and many collections on the actual questions of theoretical and practical surgery. O.V.Malnikov is one of the founders of the Ukrainian schools of oncologists and schools of gastric surgery. He prepared a large number of scientists who continued to develop his ideas.
In the development of the Surgery it is difficult to estimate the role of O.P.Krimof, M.E.Sitenko, V.P.Filatov, N.E.Koher, E.M.Esenko, N.M.Amosov, M.S.Kolomijchenko, O.E.Arutjunov, M.M.Novachek, E.I.Deineko, Z.I.Geimanovich, A.A.Sheliamova and many other Ukrainian surgeons.
Development of Ukrainian surgery (B.E.Frankerberg, E.V.Kramarenko, 0.N.Krimof) worked on problems of chest surgery, in 1948-1951, was used on wide scope. Special success on chest surgery started developing in 1952, when before Kiev's Institute of Doctors gave the first department of thoracic surgery, which was leaded by N.M.Amosov. He worked on surgical curement of pus process, tuberculosis defects, method of pneumoectonia and frontal tomia, methods of anesthesia before all these operations. By active participation of N.M.Amosov in Ukraine preparation for many thoracic surgery, in all central regions gave departments of thoracic surgery, widely stood the development of surgery of heart and vessels. In Ukraine many operations (more than 300) according to view of heart did N.M.Amosov. Surgery of heart successfully developed Ukraine, in Kharkiv - A.A.Shamov, in Lviv - M.B.Danilenko and many others. More contribution has in development of surgery M.M.Sitenko. He is known as one of the basis of Ukrainian school orthopedic surgeon - injury, talented organisator of injury help in our country. His works on questions of orthopedic help, and mainly of theoretical questions always differed actionably. His contributed more of finding of bone callus, process of degeneration of bone-tissue, gave the methods of early cure of diaphisis and epiphysis fracture in new-born with the visage of needle in particular construction, methods of cure of fracture of radius bones, fracture of bones of knee, 8-form of bandaging, worked on methods of diagnosis of suprachondral fracture of brachium and methods of cure, demonstrated to operative cure of fractures bones.
M.E.Sitenko gave big school of scientists. M.P.Novochenko, scientist Sitenko, worked on more than 100 works, many monographs, worked on original operation on big joints. Before osteomalation and bony tuberculoses, free bony plate. M.E.Sitenko in his work relatively in the organization of orthopedic injury help and prevention against injury in Ukraine was helped further in its development. M.S.Kolomijchenko opened more than 100 works, devoted surgeon of heart, pericardia, esophagus, heart spasm (cardio-spasm), plates, history of surgery, and organization of surgical help in our country.
Development of neurosurgery and organization neurosurgeon help in Ukraine was mainly worked S.E.Arutjunov. He founded more than enough in schools scientists. B.E.Geimanovich, O.E. Geimanovich are played important role in development of Ukrainian school of neurosurgery.
In experimental surgery, cure of injury, worked of the method of transformation of blood mainly contributed A.A.Fedorovski.
M.M.Molostanov mainly worked for development-emergency medical service, military-field surgery, cure of wound, introduction in practical transformation. His worked nearly about so works, fields of which book and textbook.
Modern understanding of surgery, surgical diseases and surgical works
Modern profession understands. In early surgery develop as additional medical specialty that is last 100 year this opened like this important and deep changes, that today to this might be read as one of the youngest part of medical science which might sufficiently develops fast.
If early to surgery were devoted people, which have different pathological processes, internal symptoms of disease, which in modern time narrows to explain "Common surgery". After covering anatomy and human physiology, introduction of anesthesia and methods of prevention surgical infection, surgery work about this kind of Blizzard period their development, that is many specialties, which earlier entered in compensation of surgery, assign and stood on the at of self development.
Like that, last decades of self-study - practical discipline assigned injury and orthopedic, obstetrician and gynecology, oncology, urology, and eye diseases, anesthesiology - reanimatology, otolaryngology and other diseases.
In large industrial centers of our country, like that and in all other developed countries of world, process of fort her specialization of surreal helps introduced. And in our time, reads particularly organization of this kind of help, necessary for specialty of both hands and equipment's, mainly more differentiates like self disciplines of surgery of lungs and heart, surgery of heart and major vessels, surgery of esophagus and intestines and others. Special surgical help is looked as progressive phenomenon of modern medicine.
Knowledge about "Surgical Diseases" like that continuously undersides changes. In laying tradition to "Pure Surgical" diseases has all diseases or pathological changes, which for their normalization, unconditioned, demands correction on help of arm. This kinds of injures and wounds, hernia and swellings oh different localization, death of tissue and defects of development, acute pus destruction process.
In that time occurred many diseases: which might cure how therapy, how and in surgery. This is that kind of disease like ulcers of stomach and duodenum, biliary diseases, diseases of thyroid gland, bronchoectazia, CNS, hereditary and acquired defects of heart. Before this diseases doctor must known about the serious diseases, forecast of diseases before different methods of cure, presence of complications and threat for life or health of patient. This kind of diseases are known as "conditioned surgical", because before under unfavorable conditions (bleeding, perforation of ulcer) conservative cure stands non-rational and for further cure of patient leads surgeon.
Not fare to repeal, that with the development of surgery medical knowledge, medical techniques, many diseases of human, which were earlier thought like therapy and didn't went into compensation of surgery. Therapy on the whole cress is with operative methods in special laboratories and institutes. Many more are counted into the part of "Surgical" pathology. Basically this leads to the one parts of surgery, like surgery of heart, big and small arterial vessels, bronchi-tracheal path and transplantation of kidney.
Profession of doctor-surgery complex and intensive, demands from human whole strength, many of physical, mental and neurological overstrain. Work of surgeon is not always interesting and gives to surgeon many happy and successful minutes, when he operates on serious patients, but happiness brings and many more hard moments. Operative interventions, which are directed for the better health of patient, are not always ended in success or selective results. In row of patients gives serious complications fairly and flyover outcome, that unconditioned and upsets surgeon which has did the operation. Every doctor brings serious not successful cure, because he knows that many complication might settle serious pathological or imperfective science, many not successful chances, connected with not sufficient knowledge of the surgeon. Possibility with defects in preparing of patient, or might be mistaken in usage of techniques of operation, that is not sufficient professional qualification of doctor.
Work of surgeon is hard, tensed, rarely with exhaustion. And this must know every student, that they should gather dedication to this profession. Present art of surgeon should necessary be long lasting, persistent and insistent on studying. Without all this information, we should say that surgeon should study all through his life. Not forgetting the sayings of P.A.Gerse, who said that "the most useful instrument of surgeon – is its hands", we all must not always be tempted and always should have the knowledge, that knife - always brings up cut, that might bring about not only cure to the patient, but also might hurt him. Doctor of surgery hold always improve his knowledge, should love his profession and patient, needs always to develop hand and fingers swiftness, learn to work hard, persistently and with patience. How should go the study of surgeon in medical university?
Series of teaching of surgeons in Higher Medical Establishments
Teaching of surgery is taken into account in department of common surgery, preparatory hospitals of surgery, in boarding schools. After achieving profession of doctor, further specialization and improvement are one in departments of in one of five years with the help widely developed surgical methods of cure of different diseases, departments of II, III, IV, V and VI course are not duplications of one another, but they add and does more the knowledge of student.
After studying basis of surgery in departments of common surgery students of III, IV course study classical symptoms of methods of curing series of pathological stages, and on V and VI course - they get familiar with the other methods of cure of diseases aside from classical diseases, methods of curing complicate form of diseases. Besides this, on V course students get familiar with the work many other special help - surgery of heart and vessels, surgery of lungs and thoracic organs, other pathological stages.
Not seeing all minute specializations of surgery, on the stable quiet of new methods of studying, has series of questions, which are added to basically or basis for al the proceeding processes of study in higher medical establishments. To this question works the department of common surgery where students are informed about the sections of medicine, like the department before them lays these questions.
1. Entering into specialization, knowing about (he work of surgical sections of surgical help, elements of deontology and medical ethics.
1. Brings about much professional knowledge, which forms the basis of medicine and surgery. This is that kid of question and section of surgery, like asepsis and antisepsis, basis of anesthesia, bleeding and blood loss, transformation of blood, and blood exchange, basis of injures, diagnosis, prevention and cure of surgical infections, organization of operation and talking to patients before and after operation period, series of other problems.
2. Knowing of it are very difficult, we came to know that in departments of general surgery in students formed elements of clinical thinking, which are added to over period of years and develops as a result of before many years of experiments with the work. Always necessary to know, that needs not to cure disease, which on the first existed simply, patient with psychological specialty, complex diseases and individual qualities. Not seeing, that many questions of separate pathology does not account for the syllabus of common surgery, now students should already think about the questions of operative risks, injury and seriousness of operation, adds theoretical knowledge and practical skills, which are directed. To the correction of dysfunction, which are developing in patients. We should underline that all additional knowledge which feeds students to get, study not only from books but also from monographs, periodical literature, expands only knowledge, gives confidence in work, further it will give the formation of individual doctor.
3. We will always strive fry that, that beside professional knowledge and professional skill students of this department will widen their comprehensive vital phase, fine knowledge development and perspective surgery, rightly appreciates that advantage which concludes in it governmental protection of health.
It is understood (hat teachers must he in contact with students, all the time of classes, question them. Iced them with the feeling of responsibility for their work: work with profession and simple study knowledge.
Take into notice about the importance of medical deontology and medical ethics, which we should always have in prolonged period, that should slay with while having qualifications in the university, but elements which are necessary for us to know, when we enter into the study of clinic.
Deontology, besides common principles and right, showed the form of professional moral, which has principles of "must" in short form. Public opinion of person, in given condition - is medical profession.
Medical deontology - this is the right of behavior doctor with the patients, doctor with other medical works, but like that and questions of preparing of doctors for their profession, their desire for self concluding.
Profession of doctor is one of the most humanlike, but like that in that time, and most responsible. This work is difficult, invites all human strength, this might be prepared in any minute, of day or night to go to the help of patient. This feeling should necessarily be developed in one-self, develops and feed in the prolonged period of their study in medical establishment, like that in further, in self-practical work.
All this basically doctrinal profession we should know on practical experiments. And in works with diversion of their experiment, knowledge and practical professional knowledge, which stands for us for ordinary normal reasons want to wish that clinical study works for multiply and success.
Ethics and deontology in surgery
THE FIELD OF SURGERY
Surgery is a form of service to man. It is a body of knowledge and experience developed by man to meet human needs in certain fields and has come to be entrusted to a group of individuals who have devoted themselves more or less successfully to acquiring this requisite body of knowledge and experience.
Its boundaries and those of internal medicine are more distinct in the popular mind than in practice. The practitioner of internal medicine generally abstains from performing formal operations and by doing so has more time which he can devote, if he will, to the study of diagnostic problems, for consideration of psychosomatic difficulties encountered by his patients, and for study of advances in the basic sciences or to clinical investigation.
A number of years ago one of our senior surgeons made the statement that internal medicine was becoming more and more surgical in its outlook, and, in all fairness, one must add that in the first third of the twentieth first century, general surgery has become more and more steeped in medicine and the basic medical sciences.
There is no more basic objective for the surgeon than the precept of the late John B. Deaver who said that a surgeon must be a medical man and something more-not something less.
Anyone who enters the field of surgery to escape from the rigorous mental discipline required to think straight in medicine is likely either to fail or, worse, do a great amount of harm.
HISTORICAL DEVELOPMENT OF SURGERY
The place of surgery in the whole of medicine and in our general social structure gains perspective from its historical development. The writings of Hippocrates (5th century, B.C.) reveal much valuable knowledge about the treatment of fractures, drainage of abscesses and the management of wounds. The same people practiced surgery and medicine in his day. Many of the concepts in the Oath of Hippocrates are valid today, and one cannot consider the philosophy of medicine and surgery without coming back to it.
Largely Greek physicians utilized much that the Greeks knew during Roman times. Few Romans became physicians. Even the greatest, Galen, was a Greek by birth. Medical knowledge apparently grew very little until the Renaissance, when artists and sculptors began the study of anatomy, and Vesalius wrote De Humani Corporis Fabrica (1543). During the long centuries that intervened, medical care had become a function of the clergy, and it was not until the Church ordered the monks not to operate that they started having their barbers do it. Thus there grew up a group of barber-surgeons, the best of whom devoted them to surgery.
In England, there was a brief period in the early 16th century when the surgeons were associated with the physicians, but later in the 16th century Henry VIII granted a charter to the Guild of Barbers and Surgeons, and, despite various attempts to break away, the surgeons remained organized with the barbers until 1745. The distinction is still perpetuated in England where a surgeon is addressed as Mr. Smith while a physician is referred to as Dr. Smith.
In the United States and in other countries of the Western Hemisphere this distinction has not been made. For many years all medical men performed both medical and surgical services.
During the middle of the 19th century, the development of anesthesia, antisepsis and asepsis greatly increased the range and the effectiveness of surgery, and this has been further extended by the development of roentgenology, the development of transfusion, of parenteral nutrition (including water and electrolytes) and by antibiotics. Concomitantly, a great group of surgical specialties and sub-specialties has developed. Today, the danger of overspecialization is often spoken of, but the probability is that the future will bring more rather than less specialization. The antidote to the danger envisioned appears to be a training period which includes a broad background in medicine and general surgery and some continued contact with these fields throughout the whole of one's professional life.
RELATION OF SURGERY TO MEDICINE
Surgery is very much a part of medicine in the broad sense. The fact that “medicine” is used to denote the whole field covered by the school of medicine in a university and also in a narrow sense, to denote the department of that school which teaches internal medicine, is often a source of confusion.
Certain common usages of the word “surgery” carry by implication such a slur on the profession that they cannot pass unnoticed. The British use the word as synonymous with the office of a practitioner. This usage has no place in the American language and therefore will not be commented upon. However, a common Americanism is to say that on such and such a date the patient was taken to surgery – meaning that the patient had an operation performed. The phraseology is vaguely reminiscent of taking sheep to the slaughter, but our basic objection to it is the implication that the operation constitutes all or most of what the surgeon has to contribute. This may apply to the “ghost surgeon” but not to the more creditable representatives of the profession.
Surgery is a body of knowledge not only of operative technique but also of human anatomy (gross, microscopic and ultramicroscopic), biochemistry, biophysics, genetics, physiology, pharmacology, pathology, microbiology and immunology, medicine and psychology (to mention only some of its components). This knowledge helps to determine from careful consideration of the patient’s history and physical findings what laboratory aids are needed, and on the basis of these to establish the diagnosis or probable diagnosis. One must decide whether or not there is a worthwhile chance of helping the patient by operative intervention and if so when it should be done. Only on the basis of such preoperative study can one make proper decisions at operation about what should be done. More and more mathematical technics must be used in converting these data into valid decisions. It is in recognition of this factor that a chapter on mathematical analysis of surgical data is included in this book. The surgical responsibility then continues into the postoperative period for days or weeks, providing for the patient’s recovery, averting and/or combating complications and endeavoring to restore the patient to complete health or to obtain for him the most in rehabilitation that his condition permits.
Obviously, the surgeon cannot do all these things alone. He must function as a member of a team helping to coordinate the services of clinical pathologists, radiologists, nurses, surgical house officers, social workers, rehabilitation experts and many others for the welfare of the patient.
Why, one may ask, must the surgeon concern himself with all this? Should not the job of coordination be left to the internist? In some cases the internist or general medical man can do a very good job of it. In other clinics, anesthesiologists carry major shares of responsibility in preoperative and postoperative care. Basically, however, a surgeon assumes the greatest responsibility for the patient when he operates on him. The responsibility as a rule is no less when he counsels against operation. The responsibility is of such a personal nature that it can hardly be escaped. Too often it involves life itself. A surgeon needs all the help he can get, but if things go badly when they need not go badly, the patient and the patient’s family will hold him responsible, whether it be for his own acts or failure to act or for the performance of others involved in the case.
The division of responsibility between the medical man and the surgeon may be difficult. Usually, agreement is reached on diagnostic probabilities and on the indications for operation. Then it is generally best for the primary responsibility to shift to the surgeon during the operative and the postoperative periods. Thus, the surgeon is in the position of a consultant up to the immediate preoperative period – the internist then becomes a consultant, usually until the patient is well enough to leave the hospital. This policy is supported by a broad experience, which indicates (probably without statistical proof) that the surgeon who follows his patient carefully before and after operation achieves better results than one who acts solely during the period of the operation itself.
Recently, a group of general surgeons became so alarmed by the development of sub-specialties that they proposed a special organization partially to protect the general surgeon from the inroads of men in narrower fields. Already we have the vascular surgeon, the thoracic surgeon, the neurosurgeon, the gynecologist, the urologist, the plastic surgeon, the proctologist, etc. There is no way to predict how far this process may go. It is dependent on the size of medical units. Thus, a 100-bed hospital will do well to support men in 2 or 3 of these specialties. The 1,000-bed teaching hospital probably can support most of them. What then would be possible in a 10,000-bed hospital, if such came into being? Who can say that a man who devotes 90 per cent of his time to hernia cases might not gain experience and be able to evaluate methods that would permit him to excel in this field? Another might concentrate on abdomino-perineal resections, another on gastric resections, et cetera.
It is obviously important that talent be on hand at operations to cope with unexpected findings and occurrences and especially to recognize things outside the narrowly specialized field. It is here that breadth of training appears to be an essential to safe surgery and safe medicine.
Therefore, young men entering surgery should avail themselves of broad training and education, even though they have definite plans for going into a highly specialized field.
OBLIGATIONS OF THE SURGEON BEYOND PATIENT CARE
The Oath of Hippocrates not only binds the physician to restrict his relations with patients to the care of illness or injury and to eschew social entanglements, particularly of a sexual character, but it also contains some less widely known provisions for the perpetuation of medical knowledge.
The physician was to care for his teacher as for a member of his own family and he was obligated to pass on his knowledge to the children of his teacher if they want to study medicine.
The practicing physician uses almost entirely knowledge that has been transferred to him, and he often receives payment for his services without much thought of his debt to the past. If he contributes nothing either to the transfer of old knowledge to those who must succeed him or to the discovery of new knowledge through experience or experiment, he is purely a parasite in his relations with his profession. He may still be a useful member of society as a purveyor of medical knowledge to the consumer, but he adds nothing to the continuity or progress of his profession.
The term “doctor” means teacher. The physician is expected to teach his patient’s things selected from his store of knowledge, which will be of benefit to them. He should take time to do so.
He should also teach what he can to his younger colleagues and share with colleagues of all ages’ information, which is of value for their patients. In this obligation which medicine has accepted from the time of Hippocrates it has set itself off from most fields of human endeavor where advantageous knowledge is too often restricted for the benefit of an individual, a corporation or some other special group.
While it is not given to every surgeon to make important new contributions to the science of surgery, it is the opportunity of nearly every surgeon to participate in the transfer of knowledge to others and especially to younger colleagues.
This habit may well begin in medical school and surely should be established during hospital training. As the individual becomes more senior he should still reserve time to do it, remembering that what he has to give them will be the more appreciated and often better remembered.
Such contributions by the surgeon, whether they be great or small, are not limited by place or type of practice. A practitioner in even the smallest community may be presented with the opportunity to make a contribution of consequence. Such an opportunity was presented to William Beaumont by the accident to his patient, Alexis St. Martin. This occurred under the most primitive conditions, yet the positive and persistent approach to the situation by Beaumopt led to a truly great contribution to knowledge.
Particularly in surgery much depends on clinical experience. Through a proper transfer of knowledge, the experience of one surgeon may prevent others from making mistakes that cost the lives or impair the welfare of patients. When a surgeon or a physician speaks of his experience, he includes in the term knowledge, which has come to him not only from his successful cases but also from his failures. Therefore, it is a serious obligation to pass on that which he has learned to the other members of his profession. This may be done by presenting case reports or analyses of series of cases to local or national medical societies and, if they prove to be of sufficient value, by publishing them in appropriate medical journals.
The further elucidation of clinical observations generally requires laboratory technique. The surgeon has certain peculiar advantages as an investigator, which should be borne in mind. He is in intimate contact with patients and, if he is alert to the potentialities of modern laboratory methods, he is in a key position to see significant problems, which are susceptible of solution. He may then be able to draw experts in the laboratory sciences into the study or to seek their advice in applying appropriate laboratory technique himself.
Furthermore, he has access to patients and the decision of whether and when to try a new method or a new drug in these patients is frequently his. The moral issues raised by this situation are important ones. The obligation of the surgeon is primarily to his individual patient. He must not subject his patient to an unnecessary risk, even with the ultimate objective of benefiting thousands of other people, without full understanding by and consent of the patient. The availability of individuals clearly succumbing to disease, who have more to gain than to lose by the trial of something new, does much to bridge the gap which otherwise would exist between what is good for the individual and what is good for others. Here, as everywhere in surgery, the Golden Rule is the best guide to conduct.
These vistas broaden as the fields of organ transplantation evolve, for not only is the welfare of the recipient a matter of legal and ethical concern but so also is that of the donor. Formulations of firm guidelines in these and perhaps other areas, especially when non-paired vital organs are to be transplanted, require agreement as to when the donor is dead, because the sooner the organ can be transplanted, the better the chance for its survival.
The surgeon alone has the opportunity of applying new operative technics. Furthermore, he has the unique opportunity of seeing and feeling internal lesions in the living patient. He also has certain opportunities to make physiologic observations at the time of operation and often to obtain biopsy material for histological and biochemical study.
His technical skills open certain doors in animal experimentation, particularly where survival experiments are desirable. From the time of John Hunter (1728-1793) nearly all the great surgical investigators have leaned heavily on a variety of species of animals to try out their ideas and perfect their technique before applying them to man.
Surgery, like all medicine, is an applied science, and the greater portion of the investigative work done by surgeons will consist in so-called applied research. However, the surgical investigator should not be blind to the opportunities he has of contributing to basic knowledge either in the clinic or the laboratory, and a number of contributions to fundamental biologic information have come from surgeons. Furthermore, as Sir John Bruce has pointed out, Lister’s demonstration of the value of antiseptics not only revolutionized clinical surgery but for the first time made survival experiments in animals practical. Thus a new technique of immense value in physiology, pharmacology and experimental pathology was made available. Other technique developed largely by surgeons, who have opened new possibilities in basic science, have been the heart-lung apparatus of Gibbon and long-term total parenteral alimentation.
It should be emphasized that in clinical investigation more is generally to be learned from the careful study of a few cases than from the more casual review of long series.
Studies of great scientific contributions have shown that the years from 25 to 35 are the most productive. In medicine this means that a man's best contributions are often made during his period of study and training.
Today the surgeon has an additional responsibility: engagement in the development of solutions to the problem of distribution of medical care to all segments of the population. With the growth of specialization, medical care has become concentrated in large urban communities, and in rural
THE ART OF SURGERY
In one's pursuit of science in surgery one must not become oblivious to the fact that surgery is an art as well as a science. The art is thought of often as the manual dexterity, which a surgeon must possess or acquire to do his work. This is a very important aspect but not the whole of it. It also includes much of the decision-making process, which goes on constantly at the operating table. Differing degrees of skill in this field account for one man frittering away time on unimportant minutiae while another man abridges a procedure at the expense of thoroughness, and a third man strikes a proper balance by taking time to do what is important thoroughly, without wasting it to achieve perfection in minutiae that are meaningless for the welfare of the particular patient.
A third and important aspect of the art of surgery lies in the field of talking to patients and their families. This is a most complicated art. What is said should depend on a host of perceptions of the patient's fears, of his doubts, of his past relationships with the surgeon and with other doctors. It is colored by the seriousness of the illness and the obstacles in the mind of the patient in the way of accepting treatment. It is necessarily colored by the surgeon’s age, how well known he is in the community and how he is regarded in the patient's mind. The same surgeon at 30 may need a 10-minute exposition of facts to create the same degree of acceptance for a needed cholecystectomy that he could convey to the patient 20 years later in a sentence or two. Success in this field is again partly native ability and partly acquired skill.
One of the most important prerequisites to success in acquiring this skill is a strong enough desire for such skill to make one strive continuously to improve it. One must spend time in listening to patients and to their relatives and in trying to perceive and to understand their reactions. Considerable native modesty and a strong liking for people are most helpful. It is also extremely important to know something of one’s self. When one’s inner hackles rise in irritation or anger it is time to turn one’s attention inward and to try to understand the why and the wherefore before giving vent to such feelings in remarks to the patient. While this brief discussion of the art of surgery is far from complete, perhaps it will convey some concept of what is involved.
Finally, if the surgeon is to do his utmost to advance his profession, he should endeavor to make opportunities for his younger colleagues to develop. This may require some self-denial on his part, some risk of being superseded in this field or that. If he is convinced that he is backing able and rightly motivated younger men, he should make some sacrifices and accept these risks.
OPPORTUNITIES FOR SURGICAL TRAINING
One purpose of setting forth our views about the obligations of surgeons in a textbook planned primarily for medical students is to provide a background for certain comments about the selection of training by those who contemplate specializing in this field.
How does one become a surgeon? How does he know a good residency opportunity from a poor one? If possible, select a medical school where the surgical department is interested in research as well as in teaching. If possible, obtain an internship in the best teaching hospital you can-be it medical, rotating or surgical in nature. Criteria that have proved useful in estimating the value of a hospital for internship are the following:
Ordinarily, the intern should have major responsibility in writing the orders for the patient’s care. The visiting staff should make rounds regularly with the house officers.
Do your utmost to be helpful on your hospital assignments. The unpopular assignments are often the ones where good performance will stand out most and be most appreciated.
So far as possible, steer clear of those institutions where the house is divided against itself but try to get an assistant residency in a teaching hospital. Most men are happier in a residency system that does not require progressive elimination of the fit by the more fit. The old pyramidal system which eliminates men at the end of each year may lead to competition but at the same time is apt to produce poor working relationships and bitter disappointments.
It is a good rule during one’s training period, as well as in the years that follow, to participate in at least one good scientific society meeting each year.
Finally, measure your chiefs by the standards discussed above. One who takes not only an interest but also an active responsibility in helping his men another step up the ladder and has been successful in doing so generally affords a much better association than a man of the “take you and leave you” type, no matter how brilliant.
It is often said that those who can, do and those who can’t, teach. The basic criticism is one from which surgery has so far nearly escaped. The teachers of surgery are nearly always selected from highly competent performers, and many of the best performers in surgery play key roles in teaching. Pressures have been increasing to change this pattern by selecting for teaching appointments men whose clinical finesse is attested only by board certification and whose claim to distinction is largely in related fields. We believe that the student desiring to enter surgery in general does well to seek out a department that is distinguished for its performance in clinical surgery as well as for its research contributions.
Monetary advantages during the training period should not be given primary consideration. It is usually wiser to emerge from a first-class training program in debt than to avoid the debt by accepting less than the best training opportunities for which one can qualify.
The Effect Of Decreasing Availability Of The Primary Physician On The Need Of The Specialist For Breadth Of Medical Knowledge
Some of the factors, which have tended to decrease the availability of the primary physicians, were discussed by one of us a few years ago in the Journal of Medical Education. They include: the growth in the population; the slow growth in the numbers of graduates from medical schools; the greater attraction of other fields of graduate education due, in part, to subsidization in the form of graduate fellowships; the sharp increase in intramural “residency” positions in large centers; the demands of the military services; the growth of full time faculties which devote major time and energy to research; and the decreasing willingness of physicians to work very long hours in a society working 40 hours a week or less. All of these factors and others appear to have reduced the night doctor/patient ratio very seriously – that is, the number of physicians who will respond at night to a sudden patient need, particularly if that need is undefined.
Not only is there a dearth of specialists but also there is a relative lack of generalists. In such a situation much can be salvaged if those specialists who do practice in the area are broadly knowledgeable in medicine as a whole and able to recognize pathology outside of their own fields and to help the patient to get the care essential to his needs.
While the dearth of specialists does not occur in our medical centers, even in these localities there is a dearth of generalists or primary physicians. This is reflected in an increasing demand for self-referred initial appointments in the offices of surgeons in the big cities. Those specialists who insist on a physician referral often obtain them only to find that no true doctor-patient relationship exists between the overworked practitioner who has lent his name to the referral and the patient in question.
Thus, in a day of progressive specialization of knowledge and skills, there is a rising pressure from the public for broad competence and understanding of disease. Those who would prepare themselves to take care of patients should take this trend into consideration during their course work and training periods, especially if they would serve in the geographic areas of greatest need.
ETHICS AND DEONTOLOGY IN A PROPEDEUTICS OF SURGICAL DISEASES
« A Flaring suppository » - symbolical emblem, which the Dutch doctor Van Tull Psi has offered in XVII century: « Shining by another – to be consumed itself ». This emblem opens deep essence of a deontology of treatment, demonstrating simultaneously infinity of opportunities of a reign of a principle « a mental asepsis » of the doctor, which protects life of the distressed man.
The development of the doctrine about ethics proceeds during all existence of a history of mankind. In connection with growing differentiation of specialities, in last century there was a necessity of allocation of special sections of ethics. The English philosopher Bentam for the first time has offered for this purpose the term "deontology". It is a science about a duty, professional etiquette. The deontology is especially important in those sections of professional activity, which most widely use the forms of difficult human mutual relation and responsible interactions. First of all it concerns the modern man, where the psychological influence of the doctor on the patient is taken into account.
General concepts of a deontology
The medical deontology is a science about a duty of the medical worker to the patient and society. The speech goes not only about the only professional obligations, but also about spiritual, humanity.
The questions of ethics and deontology are indissolubly connected to the person of the doctor, especially - surgeon. Long since it is accepted to identify the person of the doctor with symbolical concepts - humanity, fidelity, self-sacrifice, mercy, kindness and humanism.
Accuracy, smart, legibility, courtesy, and compulsion - feature, which allocate the doctor. They cause trust to him, irrespective of age.
Endurance, skill to own itself - these features is obligatory for the doctor, and is especial for the surgeon. Some surgeons in critical situations during operation begin to shout, to throw instruments. Such actions not only are unattractive. In this situation there is a disorganization of the assistants and operational nurse, the fulfilled rhythm of work of a surgical brigade is broken.
It is necessary to the surgeon to have such features, as patience and tolerance. «The Ingratitude, with which doctor contact so frequently, should not cause contempt for the people» (Hugo Glaser). The surgeon should be ready to listen severe reproaches both charges, as a rule, unfair and unreasonable. But whether we can argue with the parents, which just have lost the child or something to deny to the relatives just died patient?
Self-criticism, unselfishness and self-sacrifice, fidelity of the chosen trade, skill to receive moral satisfaction from the work - are important features of any doctor.
It is possible also much to speak about qualities, obligatory for the surgeon. But we shall tell some words about features absolutely incompatible to treatment, with surgery.
Indifference – is very terrible feature. The sincere emptiness, when to the man all is identical. Then the work is perceived as compulsory necessity. The doctor in such condition ceases to be the doctor. To such people not a place in medicine! For the doctor there is no last business hour, and there is last patient.
The surgeon and patient, surgeon and relatives of the patient
Mutual relation of these people - is one of the most serious problems of a deontology. At conversation with the patient the surgeon should show qualities of the psychologist. It is necessary to remember, that any man feels pavor before operation. To remove this pavor - is first task of the surgeon. The quiet sure conversation on necessity of surgical operation, experience of the surgeon, success of similar operative measures in the given clinic - elements of positive influence on a mental condition of the patient. It is necessary to permit to the patient to communicate to the convalescent patients, which have transferred similar operation.
The surgeon, whom operates of the child, deals not with one, and three patients - patient by the child both "patients" by the father and mother. The reaction of the parents to danger, which threatens to the son or daughter, can be different and unpredictable. Therefore in conversation of the doctor and parents it is necessary to adhere to rules of ethics. All knowledge and attention needs to be directed on statement of the diagnosis and treatment of illness of the child.
Mutual relation of the medical personnel
The mutual relation of the surgeons among themselves and with other medical personnel comprises serious deontology aspects. These attitudes should be based on inter-respect, mutual understanding and mutual support. Envy, gloating at mistakes of the colleagues form a undesirable psychological climate in collective, that is displayed on results of treatment of the patients.
It is especially necessary to recollect the operational medical sisters - most immediate assistants of the surgeon during operation. Their difficult and responsible work deserves the deepest respect.
New deontology problems in surgery
The rough development of surgery, anesthesiology and resuscitation opens new opportunities for salvage and treatment of the patients. The successes of surgery newborn, transplantation and real opportunity of long-term replacement of the vital functions of an organism have put before the surgeon series difficult ethical and deontology problems. This right of the patients on the complete information on a condition of the health, capture of bodies for a transplantation of the died and alive donors, intrauterine correction of series of anomalies, calture of a blood for the research which has been not connected directly to treatment etc.
The most serious discussion and attention is required by a problem of “fatal cases" and attitude to them. This question is closely connected with way of discussion by a evtanasio’s problem of a fatal case. Whether to continue sufferings of this patient, despite of desire of the patient and his relatives to interrupt them? This question necessarily requires the decision at a state level.
History. Types of the bandages, rules of application and aspirations lying to bandages
The desmurgy is study about bandages (desmos – bandage, ergon – deed, action).
It is the independent part of general surgery. This is study about application of bandages with a purpose of right treatment of damages and set of diseases.
The original dressing applied at the time of operation should provide as sufficient absorbtive material to take care of the wound secretions for at last 24-48 hours, and it should be applied well enough to remain in place for that period of time. It should provide sufficient pressure to aid in producing haemostasis. Experience in the care of operative wounds in ambulatory patients permits the surgeon to gauge very well the amount of absorbtive dressing necessary in a given wound. Following incisions of infected areas in which packing has been inserted; gauze dressings or the commercial type of gauze dressing containing a film of cotton should be applied over the wound. Pressure is obtained by placing one or two strips of adhesive on the skin across the dressing and applying a firm bandage. In the application of a simple dry dressing, as in the application of all dressings to ambulatory patients, it should be remembered, that the dressing need to be no larger than the wound to be covered. It is therefore, quite permissible, and even recommended, that the sterile gauze be cut with sterile scissors, to fit the wound rather than that a large dressing be applied to a small wound. The gauze may be held in place by either adhesive or bandage, depending on the situation of the wound.
We understand the part of practical surgery studying the application of bandages, which including two notions under the desmurgy term:
1. The bandaging material properly applying directly on the wound (dry, humid, liniment bandages).
2. The outward part of bandage, using for strengthening of bandaging material, which applied on the wound.
The bandage in the more broad sense is complex of means, which used for protection of wounds or pathological seats from the action of environment on more or less prolonged period.
In the narrow sense the bandage is material (bandage, plasters and others) applying on the wound for fixation of bandaging material with the remedies. Finally, the bandage term is process of application or changing of curing bandage with a following fixation of it.
It should mark the some general tendencies in the development of desmurgy.
Firstly, the aspiration for manufacture complex means for application of bandages, the purpose of which is guaranteeing of work medical personal by massive entrance of victims.
Secondly, the using of gluing preparations (BF-6, furoplast etc.) for protection of a wound from unfavorable outward influence in a process of treatment or securing of well fixation of bandaging material (cleol, collodium).
Thirdly, the substitution of traditional bandaging material by plastic, which secure both the protective effect and introduction of antiseptics immediately in the region of damage is owing to medicinal additions in a plastic mixture (reinforced cellulose bandage).
Fourthly, the substitution of existing gauze bandages by tubular, net bandages, which secure the quick and reliable fixation of bandaging material.
The dressing of wound pursues the following purposes:
1. Protection of wound from unhealthy influences.
2. The prevention of reinfection of wound.
3. Sometimes to stop of bleeding from the wound.
4. Struggle with infections, which present in the wound by the adsorbent and hydroscopic properties of bandaging material.
M.E. Preobragensky (1894) proved by its exact investigations in its book “Physical antisepsis”, that the bandaging material, which adsorbs well the contents from the wound, is on of the strongest methods of liberation of wound from the infection.
If we know the purpose and influence of bandaging of the wound, we can do the conclusion lightly that bandaging material is more acceptable and meet the following requirements:
1. Not irritate the wound and adjoining to it tissues.
2. Not change its properties by the sterilization.
3. Not lose its properties by the prolonged keeping.
4. Have the convenient form and above all have high suctionable.
Thus, the cotton wool, gauze, lignin are the favorable materials for bandaging. These are three kinds of bandaging. These three kinds of bandaging material are affirmed solidly in a surgery.
White cotton wool using for bandaging is consist of long and thin fibers. It is necessary to deprive of fat the cotton wool that is should be suitable for absorbing bandages. It is necessary to bleak it in a chloride of lime and stay on the air at some time after deprivation of fat. Then it is washed well by weak hydrochloric acid solution for neutral reaction. Then it is washed well by water and dryed. The lamp of such cotton wool sinks in water quickly since it is absorb the water quickly.
Grey, not depraved of fat cotton wool used in a medical practice for protection of diseased place from external influences, compresses, line with a plaster bandage etc.
The second very popular bandaging material is gauze. The gauze is soft cotton fabric cloth, produced from the deprived of fat cotton wool. There are many kinds of gauze. In medical practice two-three kinds, which must meet the set of requirements, are using. The bandages most commonly are used of 32 x 28 mesh gauze.
Only deprived of fat gauze and able to absorb the liquid is suitable for bandaging.
Two kinds of gauze is used in a medical practice: the less thick bandaging gauze, which have 7×8 threads on the square centimeter, and more thick bandaging gauze, which have 14×14 or 17×17 threads on the square centimeter. The first is absorbed the liquid more quickly, the second – slowly, hovered it is more firm then the first.
Elastic adhesive tapes. Several manufactures have placed in the market cotton-webbed bandages, which are overlaid on the side with adhesive. These bandages are excellent for use when the fixation of a non-adhesive bandage is somewhat difficult.
Lignine is mechanically and chemically processed wood of conifers and deciduous trees. The color of lignine is yellow-white. It absorbs the moisture pus well. It endures the sterilization lightly.
Paying attention on this, the lignine use for such wounds, by bandaging of which is necessary change the bandage often.
The types of bandages.
There are following types of bandaging by character and purpose:
1. Simple, soft, protective or medicinal.
2. Compressive (haemostatic).
3. Retaining (immovable), transport and medicinal.
4. Extension (bandages with drawing out).
5. Corrigating for unlooding of bones and joints, corrections of faulty postures.
Depending on material using for fixation they are distinguish. (see appendix 5)
7. Soft bandages (bandage, contour, scarf, sling and others).
8. Hard bandages (transport and medicinal splints, orthopedic apparatus, prosthetic appliances, corsets).
9. Hardening bandages (plaster, zinc-gelatinous, starch, bandages from polymeric materials).
Soft bandages (see appendix 4)
stockinet tubular (net) bandages;
elastic cloth bandages.
a) synthetic glues (cleol, collodium, BF etc.);
b) adhesive plaster.
a) standard contour (suspensor, bandage, retelast etc.);
b) individual contour (produced by the necessity) (B.I.Dmitriev).
Bandage – is long stripe of gauze or other mater – intended for strengthening of bandaging material or securing of immobilization of locomotors apparatus (by impregnation of it by hardening substances – plaster of Paris, starch).
Gauze bandages are basic materials till now, which used by the bandaging. They have different width (5 – 20 cm) and length (2 – 7 m). The narrow bandages are using for application of bandages on the fingers and hand, wide – for bandaging of abdomen, pelvis, chest, hip etc.
The bandages can be used repeatedly after aseptic procedures. They are soaked in a 3% solution of hydrogen peroxide with 0,5% of detergents and autoclaving. Launder in soapsuds by the temperature 35 – 37 °C, rinse and dry.
The medical tubular bandages use for fixation of bandaging material on any part of body. They are produced in rolls. It contrasts to usual bandages they are not reel, but get on injured region of body. They fixed the bandaging material as a result, and not prevented to movement in joints by this.
Elastic cloth bandages are conforming mainly in traumatology and sport medicine.
Glue bandages – are used for protection of open damages and superficially localized inflammatory processes. They secure the strengthening of bandaging material, laded above the wound.
Cleol – the canipholy – 40g, 96% ethyl alcohol – 33g, ether – 25g and 2g of sun-flower-seed oil are in composition of it.
Collodium – consists of 48g of colorsiline, 76g of ether and 20g of 96% ethyl alcohol.
Collodium, and glue BF-6 more better, can be used for protection of aseptic after-operational wound the gauze, by dint of growing of sterile glue on the surface of not great wound (protective pellicle).
Adhesive plaster – is used for protection of fresh not soiled wounds and as a fixing mean of bandaging material. Adhesive plaster is used for rapprochement of wound edges too. It is used for adhesive plastered drawing out by the break of pipe bones in a pediatric surgery.
Scarf bandages – are pieces of material by three-cornered form. It used as a fixing mean of bandaging material, especially by the rendering first aid.
Sling bandages – are cut two sides stripes of gauze as many other material strengthening of bandaging, material on the nose, chin, occipital region.
Contour bandages – are cutting out from the piece of water by the profile of closing by bandage part of body. The contour bandages are fastened with the help of sewed braids. In a number of cases of contour bandage of abdomen is used for strengthening of front abdominal wall. Suspensor is consists of equipment and purse. Use after herniotomy, by the inflammatory diseases of testicle, penis or scrotum.
Elastic net-tubular bandages are produced from India rubber, which braided by cotton wool thread. This net, like a stroking (from 5 to 20m) of seven sizes (0 - 6), is use for fixation of bandaging material in any part of the body.
Dressing of Infected Wounds. The patient with an infected lesion should be asked to return for dressing on the second day after operation. As a rule, it is unwise to change the dressing on the day following operation, since this usually sets up renewed bleeding and the secretions are usually not excessive enough to demand a change of the dressing.
On the second day after operation, the superficial dressings are removed and the wound is inspected with the packing or the drainage still in place. The surgeon then decides as to the type of dressing to be applied and this must be done before the instruments and the dressing tray be spoiled. He should be provided with sufficient cotton balls soaked in hydrogen peroxide to wash away the dried secretions on the edge of the wound and to use as sponges in removing purulent secretions from the wound itself. A few alcohol sponges are useful for a final cleaning of the skin round the wound. If packing is replaced, it should reserve sterile instruments for removing packing from its sterile container and for cutting it with sterile scissors without contaminating the remainder. Unless the packing in the wound seems to be acting as a plug and preventing drainage of the wound secretion, it is usually wise to leave it in place or to remove it only in part at this dressing because, at this time, a sufficient amount of inflammatory induration has not developed in the walls of the wound to keep its lips from falling together. It should be mentioned in passing that, when gauze packing is adherent to the edges of the wound, considerable pain is experienced by pulling it away at this second day dressing, whereas it usually is easily removed without pain at later renewals of the dressing.
After this initial dressing, the interval between future dressings depends to a great extent upon the amount of secretion. If it is profuse, daily dressings are necessary, whereas, if the breakdown of sloughing tissue is slow, dressings may be maintained for 2 or 3 days. Usually, at the second dressing all packing is removed from the wound, and by this time, if an adequate incision has been made, an opening of sufficient size remains. Unless the infected area is deep, there is no necessity for reinserting packing or other drainage material. The inflammatory induration in the walls of the wound will not permit its closure until all the purulent material has been discharged. When the wound is exposed, an effort should be made to remove all the liquid necrotic material and as much of the loosened area of necrosis as possible.
Two methods are of particular value in the removal of liquid material. The easier and the more painless method is the irrigation of the wound with warm sterile saline solution. The glass syringes with rubber bulbs or the disposable sterile plastic bulb syringe have been found to be most useful in this connection; they may be handled with one hand and the force of the stream regulated so that the solution may be forced with good pressure into the deeper recesses of the wound cavity. This method of cleaning the wound is of particular value when the wound is deep and when there is considerable sloughing fascia and connective tissue.
In surface infections, the liquid secretion and the slough may be removed by mopping the wound surface gently with a cotton sponge moistened in saline or hydrogen peroxide. Once the wound and the surrounding tissues have been cleaned of purulent material, areas of sloughing tissue, which have not yet liquefied may be seen. Often these areas may be loosened gently by applying slight tension with forceps or they may be cut away carefully with the scissors from the surviving tissue adjacent to them. If the sloughs are not loose, it is better to leave them alone until the next dressing rather than to run the risk of causing the patient pain and of setting up bleeding.
When the wound and the surrounding tissues have been cleared of purulent secretions, it is often well to bathe the skin round the wound with 70% alcohol on a cotton sponge. This may prevent the infection of the hair follicles in the adjacent skin and the furunculosis, which not infrequently occurs. When the secretion is profuse, an excoriation of the surrounding skin may develop. This is treated by the application of a small amount of zinc oxide ointment after it has been thoroughly cleansed and bathed with 70% alcohol.
Dressings are continued daily or every following day as long as there is much drainage from the wound. Moistening the dressings prevents crusting and permits the escape of the wound secretions. It should be borne in mind, however, that the best results are obtained and maceration of the skin is avoided by permitting the dressing to dry at frequent intervals, so that after the fourth or fifth day the dressings need to be moistened only once or twice a day.
As soon as the entire slough has disappeared and when the wound is covered with a base of granulation tissue, an effort may be made to hasten the closure of the wound by pulling its edges together with adhesive straps. Generally, this is necessary only in cases in which there has been considerable skin slough, as, for instance, following incision and drainage of a carbuncle. In few such cases, epithelization may be hastened by the application of pinch skin grafts (S.I.Shevchenko).
The technique of application of soft bandages
Maintenance of set of rules by the application of soft fixing bandage secure the implementation of laying claims to ready bandage in a full measure.
1. It should be impart about comfortable posture to patient. He must lie or sit. It is best if the suffered part of the body situated roughly on the level of human chest, which rendered the aid.
2. The bandaging part must be absolutely immovable in a process of bandage application. The extremities must be in a media-physiological posture, which is assured the maximum relaxation of muscles.
3. Surgeon must be in the face of patient, because he must react on the giving by bandage pair.
4. The bandage applied centripetal (in the direction from periphery of extremity to trunk) and started with fixing turn.
5. By the typical application the bandage is holding in a right arm, loose and (beginning) – in a left one.
6. Roll out the bandage from left to right not tearing of arms from bandaging surface.
7. Every following turn must cover from half to two thirds of previous turn wide.
The claims lying to ready bandage
1. The bandage must fix solidly the injured region till the following bandaging.
2. The bandage must be applied compactly, but not tightly, and must not put to inconveniences to patient.
3. The bandage must lie smoothly, without the creases and be beautiful.
4. The bandage must exert the even pressure upon the proper part of body and must not dangle.
5. Knot of bandage endings must not be under the damaged region of the body.
6. The bandaging material must not lose its properties by the prolonged sterilization.
7. The bandaging material must not lose its properties by the prolonged keeping.
8. The bandaging material must be highly hydroscopic and inexpensive.
The basic types of bandages
1. Circulation bandage. It is comfortable by the bandaging circular surface. Every following turn cover the previous.
The region of application: lower third of hip, shoulder, and ankle joint.
Shortcoming: can rotate displacing the bandaging material.
2. Spiral – is applied on extremities, trunk, and chest. The bandage is very simple and applied quickly, but can sleep lightly.
3. Creeping bandage – used for fixation of large by area bandaging material on extremities.
4. Cross (figure – of – eight) bandage – is applied on the surfaces of body which differing by form (volume). The forms of bandage make the figure of “8”. Occipital region.
5. Spike bandage. Shoulder joint, supershoulderic and axillary region, coxofemoral joint.
6. Tortoisal bandage – branching off and meeting, is applied on large joints (knee, elbow, ankle).
7. Recurrent – is applied on the sump after amputation of extremity, hand or foot.
8. T-bandage – is applied on perineum or axillary region.
The variants of bandages by localization
The bandages on head and neck – needed in the presence of bleedings. Circularly bandage is used for covered of the forehead, temporal and occipital regions.
The Hippocrate’s bandage and cap are used for covering of all fibrous part of head.
The bridge – is on the cline region. The slink bandage is applied on the nose, forehead and occipital region. The figure – of-eight – is on the occipital region.
Bandages on the chest, thoracic girdle and upper extremities: spike and cross, scarf bandages, and spiral bandage. The fracture of clavicle, contusion or dislocation of shoulder – need the Desault’s and Velpeon’s bandages.
The bandages on forearm and shoulder – are spiral, tortoisal. On thumb – spike bandage. On others fingers - spiral bandage of “gountlet” type.
On wrist joint –we put cross bandage. Bandages on the abdomen and pelvis are adhesive, plasteric and spiral bandage. On the pelvis, inguinal region, perineum, and coxofemoral joint – different variants of spike bandage.
On the heel region –put the branching off tortoisal bandage.
The bandages from medicinal net-tubular bandage (retelast) prefelable are more to use on upper and lower extremities.