Historical Tx of Otitis Media

I want to share this section of the old textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD (1908) mainly because I want to share the photo of the “angular knife for incision of the tympanic membrane” with you.

Otitis Media

This is a common disease of childhood, usually following a cold in the head. The prominent symptom is earache. Every physician ought to be able to recognize the bulging outward of the membranum tympani and to relieve the pressure by incision of the membrane at the most favorable situation – viz., the inferior and posterior portion. The introduction of warm olive oil into the external meatus will sometimes relieve pain, and the application of external heat may also be tried; but the pain of a severe earache, unless relieved by puncture of the membrane, usually demands the internal administration of morphine. The membrane usually ruptures spontaneously in the course of a day or two. Pain is then relieved, and a muco-purulent discharge begins and continues for a time. After it ceases the membrane soon heals over. While the discharge continues, the treatment consists in cleanliness. The ear should be syringed gently once or twice a day with warm normal salt solution, and wiped dry with absorbent cotton.

Unfortunately, this simple termination is not the only one which is possible, for inflammation of the middle ear may extend to the mastoid cells, and result in abscess within the cavity of the mastoid bone. If prompt drainage is not instituted, the suppuration may extend into the lateral sinuses and to the membranes of the brain, causing the death of the patient. Hence the necessity of early recognition of the disease and prompt treatment before these serious complications have arisen.

The external ear should be cleansed by washing it with small cotton swabs wet with a warm antiseptic solution, and the membrane anesthetized by the instillation of a few drops of a ten per cent solution of cocaine. An ear speculum should then be introduced, the membrane inspected by reflected light or a headlight, and incised in its lower and posterior portion by means of a long slender scalpel bent in the handle at an angle.

Figure 18 shows the normal membrane, and the correct size of an incision, which should be sufficient length to permit the escape of the pus and mucus. Figure 19 shows a good knife for making the incision.

When the incision has been made through the bulging membrane, a few drops of pus and mucus and often a little blood will escape. Irrigation is not necessary, but the auditory canal should be sponged clean with cotton-tipped probes dipped in a warm antiseptic solution. In the case of a nervous or restless child, it is best to perform this operation in general anesthesia. The incision can then be more accurately made.

The after treatment consists in cleanliness. The canal should be wiped or washed clean, and the inner ear protected from temperature changes by a small cone of dry absorbent cotton introduced after each cleansing and as often as the previous cone becomes moist.

Historical Surgical Drains

Updated 3/2017-- photos (except my own) and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one. 

Today, I’d like to share the section on surgical drains from the old surgery text, A Text-Book of Minor Surgery by Edward Milton Foote, MD, I first mentioned on Monday.

Glass and Metal Drainage Tubes

The use of rigid tubes for drainage is not now so general as it was at one time. Glass tubes are easily cleaned both inside and outside, and it is easy to see whether they are clean or not; but owing to their rigidity, they are apt to cause pain, so that their field is a restricted one. There are instances in which it is important to use a tube which will not collapse, and then a glass, or hard rubber, or metal tube is employed; but the ordinary purposes of drainage are accomplished just as well by the use of a flexible rubber tube, or one of the still more flexible gauze drains. Glass drainage tubes cost from ten to forty cents each, according to their shape and size.

Soft Rubber Drainage Tubes

Rubber tubing of various calibers forms a satisfactory material for drainage. Such tubing costs from seven to twenty cents a foot, according to the size and quality. The drainage tube can be prepared from a piece of tubing as follows: A piece of tubing of the required size, and having a smooth surface, is selected and cut to the required length. The end which enter the body is cut obliquely, and its sharp edge trimmed away with a pair of scissors. With a pair of curved scissors two or more oval openings are cut in the sides of the tube, beginning near its inner end, so as to permit the escape of pus in case the end of the tube is obstructed by contact with the tissues. The long axis of these openings is made parallel to the long axis of the tube, so that the tube shall not be unnecessarily weakened. A little practice will enable one to cut these openings neatly; or if one is very particular, then they may be burned out with a Paquelin cautery. This gives an opening with a smooth rounds edge, like the opening of a velvet eye catheter. (photo of Paquelin cautery – credit)

Catheters make excellent drainage tubes. Additional holes should be cut in them if necessary. The rounded tip may be left or removed, according to circumstances. If it is allowed to remain, insertion of the drainage tube is thereby facilitated.

In draining large wounds, and especially if irrigation is to be employed, two tubes should be used and fastened together at the top by a safety pin. This insures freer drainage and allows the irrigating fluid to flow into one tube and out of the other.

Gutta-percha Drains

Gutta-percha tissue is an excellent drainage material, especially for fresh wounds. It is employed in two ways: A piece of tissue, an inch or two wide, is folded upon itself until it makes a strip a half inch wide, more or less. Such a flat strip occupying very little space in a wound, and not adhering to the tissues, scarcely disturbs the aseptic healing of a wound. It is frequently inserted between the sutures of a wound at the close of operation in order to facilitate the escape of blood and serum. Moreover, if the operator is not sure of his asepsis, a drain of this character will allow the escape of any pus which may form, and prevent its burrowing in the deeper tissues. Two days after operation the wound should be re-dressed. If its appearance is satisfactory, the rubber tissue drain is removed, and the wound is allowed to unite primarily. If there is a seropurulent or purulent discharge the surgeon may decide to allow the drain to remain in place longer, or he may think it better to remove some of the sutures and introduce larger drains.

Cigarette Drains

Gutta-percha alone gives a flat drain; combined with gauze it forms a found or oval drain. This is know as a cigarette drain. A roll of gauze of the required size is wrapped with rubber tissue, as the tobacco in a cigarette is wrapped with paper. hence the name “cigarette” drain. The gauze should project slightly from the lower end of the drain, and should not be too tightly rolled. If the gutta-percha tissue shows a tendency to unwind, its edge may be stuck down with chloroform. Drains of this character are often employed in deeper wounds, for the same reasons that a flat gutta-perch drain is employed in shallow wounds; for example, after appendectomy, when there is a possibility that suppuration may form in the deeper tissues. Such a drain can be easily removed, since the only portion which can become adherent is the gauze at its lower end. For this reason the gauze should not project far beyond the gutta-percha tissue.

When gutta-percha tissue grows old it becomes brittle; hence it should be tested before it is used as a drain, lest a portion of the drain break off and remain in the wound. The tissue can be cut with scissors or torn. It has a distinct grain, so that in tearing it in one direction the motion should be quick; while in tearing it in the other direction, one must tear it very slowly in order to follow a straight line.

A finger from a rubber glove, or a finger cot from which the tip has been cut away, makes an excellent casing for a cigarette drain.

Gauze Drains

Gauze is often used for drainage, either plain or impregnated with different chemicals. Its chief disadvantage is the fact that it adheres so closely to the surface of the wound. These adhesions give way in five days to a week, but by that time granulations may already have grown into the meshes of the gauze. In spite of this drawback, gauze is used for drainage far more than any other material, both because it is always at hand, and because it is so flexible. It is not, however a good thing to use in the case of a sensitive patient on account of the pain caused by its removal. The most favorable time for the removal of a gauze drain is five or seven days after its insertion in a fresh wound.

The gauze drain may be of any size. A flat drain is formed by folding in the edges of a strip of gauze so that no loose threads appear. The two ends of the strip are then brought together, and the fold is inserted into the wound. This method facilitates the insertion of the drain, and also prevents loose threads from remaining in the wound when the drain is withdrawn.

A roll of gauze may be covered with gutta-percha tissue, making a cigarette drain. In this manner adhesions between the gauze and the surface of the wound are effectually prevented, and the drain can be easily removed at any time.

A Handkerchief Drain

If the wound is a a large one, and it is desired to keep it distended with a large quantity of gauze, adhesions may be reduced to a minimum by adopting the so-called Mikulicz method. This is also called a handkerchief drain. A single layer of gauze like a handkerchief is spread over the surface of the wound, and poked into all the recesses into which it is desired to carry the drains. Large flat gauze drains made in the manner above described are then carried into the different portions of the wound. The handkerchief limits adhesions between these central drains and the wound, so that they can be removed without much difficulty at any time. When they have been removed, the handkerchief itself being only a single layer, can be peeled off from the surface of the wound to which it is adherent.

Horsehair Drains

Small drains may be made of threads or horsehairs, by tying a number of them together, twisting the bundle, doubling it on itself, and allowing it to twist backward. Drains of this character are especially serviceable in scalp wounds, on account of the ease with which they can be inserted between the stitches.

Mammostat

Updated 3/2017-- photos and all links (except to my own posts) removed as many are no longer active and it's easier than checking each one.

I find this to be a fascinating instrument. It is to be used during the de-epithelization of the breast pedicle of a reduction mammoplasty.

I was taught to use an Esmark bandage to wrap the base of the breast to aid in the de-epithelization. It acts as both a tourniquet and makes the process simpler as the breast remains “fuller.”
I saw the ad in a journal recently and went to their website. The site shows how to use the Mammostat. I wonder if it is easier to use than the Esmark (which is very easy to use). Curious about the cost, I called and was told it is $299. It is reusable which the Esmark is not. So it might have long term cost savings.
Other Posts:
Breast Reduction (December 19, 2007)

Sponge Count

 Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active and it was easier than checking each one.

It’s one of those things you do (or rather the OR staff does) at the end of a case.  I usually continue to sew the last layer of skin as the count occurs.  If there is ever a question, then I may help locate a “missing” sponge or lap.  Usually (in my cases) they are just bunched together or one got tucked into the drapes.  That will mean that the first “final” count was wrong, but the second “final” count correct. 

Apparently, according to a recent article in the Annuals of Surgery that was quoted in the AMA News: 

While cases of retained foreign objects are rare -- occurring once in every 5,000 surgeries -- discrepancies in counts happen in 13% of surgeries, according to an August Annals of Surgery study.

I can honestly say, all the counts on all the surgeries I have ever done  have been correct.  No sponges, laps, needles, or instruments have been lost.  My cases now are more organized than some of the major trauma cases I was involved in during my training.  I can see how the counts were sometimes off.  When you have what amounts to 2-3 different surgery teams (neuro, ortho, and gen surgery) all working on a single patient at the same time, it can get chaotic.  In times like that, you sometimes wonder if the initial count was correct.  In other words, sponges, laps, needles, etc don’t have to be lost for the final count (end of case) not to match the initial count (beginning of case).

My fear of loosing a sponge in a breast case means I don’t use them.   If they come in the pack, I ask the scrub tech to put them on the back field to be used as part of the dressing.  Years ago, I finally managed to make the “the powers that be” see that if the count was correct, then it was wasteful to not use the clean sponges as part of the dressing.  If an x-ray did need to be done for any reason in the recovery, I would happily just change the tagged sponges out for them.  Hasn’t happened (knock on wood).

I use lap sponges (see above photo) with the blue tags.  This tag helps keep them from being lost.


There is a push to get hospitals and surgery centers to buy gadgets (photo credit) like the SurgiCount's Safety-Sponge™ System featured recently over at Medgadget.  The surgical sponges are individually bar-coded and then counted with the portable scanner.  This would work nicely on scheduled cases, but I wonder how well it would work on those trauma cases when the sponges are needed three minutes ago.  Would be interesting to see it in action on those cases.

 SurgiCount Medical website


REFERENCES
Sponges, surgical instruments miscounted in 13% of surgeries:  Getting the count right in the operating room is a challenge. New technologies could make things easier.  By Kevin B. O'Reilly, AMNews, Sept. 22/29, 2008.
"The Frequency and Significance of Discrepancies in the Surgical Count," abstract, Annals of Surgery, 248(2):337-341 August 2008; Greenberg, Caprice C MD, Regenbogen, Scott E MD, Lipsitz, Stuart R ScD, Diaz-Flores, Rafael MD, Gawande, Atul A MD
NoThing Left Behind: A Surgical Safety Project to Prevent Retained Surgical Items

Surgical Loupes

Updated 3/2017--all links removed as many are no longer active and it was easier than checking each one.

I received my first surgical loupes as a first year plastic surgery resident. They are 2.5X loupes made by Designs for Vision. I still have and use them. My second pair of loupes was a 4X from Zeiss which I find heavy and difficult to wear. It is exciting to get your first (and next pair and next) pair of loupes! It is also humbling to wear them the first time and get nauseated because you moved you head too fast and too often. Practice at home with anything -- reading, sewing on a button, disarticulating a chicken wing, just looking at your fingers.

I found the following history of surgical loupes in the chapter on "The History of the Operating Microscope" in the book The History of Modern Cataract Surgery by Marvin L. Kwitko, Charles D. Kelman. You can read it on-line as part of Google's eBooks and see the pictures there of the early loupes.

The history of the surgical microscope dates back to 1876, when simple loupes that attach to the spectacle frame or to a headband became available. These were made of convex lenses that were decentered to allow convergence and to use the prismatic effects of the periphery. C Von Hess used such a loupe together with an electrical illumination device attached to a headband. In 1886, a mechanic named Westien constructed a binocular instrument from two loupes to be used by a zoologist. Zehender later attempted to modify this instrument for use in ophthalmology, giving rise to the Zehender-Westien double loupe. It had a firm base and a lens for lateral focal illumination. Further development of a binocular magnifying instrument progressed along two pathways: one for diagnostic purposes and one for surgical use, leading to the eventual development of the slit-lamp and the corneal microscope. This instrument gave a magnification of 5X-6X, but had to be worn on a headband, which was one of the drawbacks of these original surgical magnifiers. The instrument was heavy and, although Westien tried to reduce the weight of these loupes to facilitate their use, it remained too heavy for the surgeon, and, hence, never became popular.

By 1912, Von Rohr and Stock had constructed a spectacle loupe that was lighter and less magnifying than Westien's. This had a working distance of 25 cm and a magnification of 2X. Gullstrand was the first to use these loupes of Von Rohr. This led to the development of a binocular loupe that could be attached to spectacles and bifocals, a model that is still used today by ophthalmic surgeons for a variety of surgical procedures. By simply tilting his head, the surgeon can view the field either through the spectacle lens or through the loupes, thereby allowing him to make use of the magnification only when needed during the procedure. It was found that a magnification of more than 2X was not desirable, due to the fact that the slightest movement of the head would cause large movements of the image because of the high magnification. These movements led to difficulties in handling tissues. Furthermore, optical principles prevented a magnification of more than 2X with these loupes. It therefore became evident that a stable device was needed for higher magnification in surgical procedures.

Binocular surgical loupes are used by many surgical specialties. There are times when they are preferred over the operating microscope. These would include any procedure when the patient's position and /or surgeon's position make it difficult or impossible to use the microscope. Other times, not as much magnification is needed to warrant the use of the microscope. The microscope is necessary when doing vascular anastomoses on children or vessels less than or equal to 1.5 mm.

Wearing surgical loupes can be a challenge, especially in long cases. The higher the magnification, the heavier they are. These are the common problems encountered when wearing them:

• Slippage of the glasses down the nose -- Anyone who has ever worn glasses know this issue. It is worst with the added weight of the loupes. This can be decreased by using tape to attach the browbar of the glass frame to the forehead. Another trick is the use of a long cord or band attached to the earpieces and tightened behind the head. This can be difficult to work with if you add a headlamp into the mix. The newer loupes have a built-in or clip-on headlamp.
• Postauricular pain -- Increased by the length of time the loupes need to be worn and be the weight of the loupes. This can be helped by preventing slippage and by padding the ear pieces.
• Discomfort on the nasal bridge -- This is dependent on the nosepiece, the weight of the loupes, and the length of the procedure. If possible, change the nosepiece or pad it.
• Fogging of the glasses -- This is caused by breathing behind the mask (which can't be helped). You can decrease or prevent the fogging by taping the top of the mask to your skin creating a barrier in this area. It is best to use paper tape to prevent skin irritation from the tape/adhesives.

There are many companies that make surgical loupes. Here are a few:
Designs for Vision
Keeler Surgical Loupes
Sheer Vision
Surgical Acuity
Zeiss
REFERENCES
A Practical Guide to Surgical Loupes; J Hand Surg (Am), 1997 Nov: 22(6):967-74; Baker JM, Meals RA

Comparison of the Operating Microscope and Loupes for Free Microvascular Tissue Transfer; Plastic & Reconstructive Surgery. 95(2):270-276, February 1995; Serletti, Joseph M. M.D.; Deuber, Mark A. B.A.; Guidera, Paul M. M.D.; Reading, George M.D.; Herrera, H. Raul M.D.; Reale, Vincent F. M.D.; Wray, R. Christie Jr. M.D.; Bakamjian, Vahram Y. M.D.

Keeping Spectacle-Mounted Loupes on Comfortably; Plastic & Reconstructive Surgery. 99(2):591,592, February 1997; Graham, Kenneth E. F.R.C.S.(Ed), F.R.C.S.(Glasg)

How to keep your glasses on painlessly(Letter); Plast. Reconstr. Surg. 69: 1026, 1982; Zuker, R. M.

Adhesive Bands to Prevent Fogging of Lenses and Glasses of Surgical Loupes or Microscopes; Plastic & Reconstructive Surgery. 117(2):718-719, February 2006; Karabagli, Yakup M.D.; Kocman, Emre A. M.D.; Kose, A Aydan M.D.; Ozbayoglu, Ceyla A. M.D.; Cetin, Cengiz M.D.

SurgeXperiences 121 and Mother's Day!

Updated 3/2017--links removed as many no longer active

Necessity is said to be the mother of invention. Mother's Day is then the perfect day for this edition of SurgeXperiences (121). The host The Sterile Eye chose surgical instruments as the theme. What a great edition! You can read it all here.

Happy Mother's Day!

Dermatomes

Updated 3/2017-- photos and all links removed as many are no longer active and it's easier than checking each one.

dermatome /der·ma·tome/ (der´mah-tom)
1. an instrument for cutting thin skin slices for grafting.
2. the area of skin supplied with afferent nerve fibers by a single posterior spinal root.
3. the lateral part of an embryonic somite.

It's the first definition that I will be discussing.

Padgett invented the first dermatome in 1939. This one was a drum dermatome and was manually operated. It was a surgical instrument for easily removing large flaps of skin of a prescribed depth. This helped move skin grafting to common practice from a miraculous one.

Today dermatomes can be operated manually, air-powered, or electrically. Many are named after their inventors. There are what I would consider three main types:

Blade dermatomes

• These provides rapid harvest of large grafts of uniform thickness. These may be air powered, electric, or manually operated.
• All of these harvest by the same mechanism: a rapidly oscillating side-to-side blade is advanced over the skin with thickness and width settings adjusted by the surgeon.
• Commonly used dermatomes include the Castroviejo, Reese, Padgett-Hood, Brown, Davol-Simon, and Zimmer
  
• When using the air or electric powered dermatomes, the operating surgeon must be familiar with the installation of the blade and how to adjust the setting for graft thickness and must check these before operating the device. There is a correct and an incorrect orientation of the blade, and the two may easily be confused.
• Insertion of a No. 15 blade scalpel simulates a thickness of 0.015 inches and can be used to check that thickness settings are uniform and correct. After the blade orientation, width guard and depth setting are confirmed, and harvesting may begin.

Drum dermatomes

• Drum dermatomes are less frequently used today but are available for specialized grafting needs.
• On these instruments, the oscillating blade is manually powered as the drum is rolled over the skin surface. These dermatomes can be used to harvest broad sheets of skin of exacting thickness.
• They are useful when the donor site is irregular, with a convexity, concavity, or bony prominence (neck, flank, buttock), because the skin to be harvested is first made adherent to the drum with a special glue or adhesive tape.
• These dermatomes also allow precise irregular patterns to be harvested by varying the pattern of adhesive applied to the skin and drum.
• Disadvantages include the risk of injury to operating personnel by the swinging blade, the need to use flammable agents such as acetone or ether to cleanse the donor site and remove surface oils to ensure secure adhesion of the skin to the dermatome drum, and greater technical expertise required to safely and effectively operate these devices.
• Reese and Padgett-Hood are examples of this type. Check out the 5th reference article.

Free-hand Knives

• Called knives and not dermatomes, these still fit the definition. Examples include the Humby knife, Weck blade, and Blair knife.
• The disadvantages include grafts with irregular edges and varying thicknesses. As with the drum dermatomes, greater technical expertise is necessary, and graft quality tends to be operator dependent.
• Check out this link on "preparing a Humby knife"

REFERENCES

1. Hand Knife Versus Powered Dermatome: Current Opinions, Practices, and Evidence; Annals of Plastic Surgery. 57(1):77-79, July 2006; Tehrani, Hamid MBBS, MRCSEd; Lindford, Andrew MBBS, MRCSEd; Logan, Andrew M. FRCS (abstract online)

2. Skin, Grafts; eMedicine Article, Feb 17, 2006; Don Revis Jr MD and Michael Seagle MD

3. Applying Split-Thickness Skin Grafts: A Step-by-Step Clinical Guide and Nursing Implications; Ostomy/Wound Management , Volume 47, Issue 11, November 2001 , Pages: 20 - 26;

4. History of Skin Grafting; Brown University Online Article

5. Grafting of Skin: Advantages of the Padgett Dermatome; Calif West Med. 1942 July; 57(1): 16–18; George Warren Pierce