One of the oldest forms of medical treatment is described in Genesis 2:18, 21-23, where the Creator Himself “caused a deep sleep” to come upon Adam while He took out the rib, closed up the incision, and made a “help meet for him.” Relief of pain is intimately associated with the rendering of needful medical care.

This is one of the physician’s cardinal responsibilities. For certain patients, some forms of severe pain may be life threatening. However, in the case of most effective pain relieving medications, addiction can occur, with distortion of mental imagery to the point of serious impairment.

Thus, it is wise to look for the simplest methods of relieving pain when attempting to perform surgery. Probably the oldest form of pain relief is refrigeration anesthesia. Extremities can be rendered pain free with ice packs. This is particularly valuable in the case of vascular disease where cardiac and circulatory impairment makes general anesthesia risky.

During the World War II, army medics discovered that troops suffering from frostbite might save their limbs if the extremity remained frozen until medical care could be secured. This observation influenced all currently accepted first aid for frostbite used in our country.

In order to properly administer refrigeration anesthesia, the extremity needs to be cooled to the point of numbness, while keeping the remainder of the body warm to avoid a general drop in temperature, chilling, or agitation. Ice packs or snow can be used to progressively cool an extremity, either a hand or foot.

If the surgery is to be localized to the arm or leg, place the pack just above the site of amputation. This reduces blood loss and allows for a careful, meticulous dissection of the tissue. Broken bones can be set with refrigeration. In the case of a simple fracture of the hand or wrist, immerse the extremity in ice water for one-half hour or more.

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

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

Counterirritation can also be applied with electric stimulation near the point of incision. This can utilize DC current, but it is more effective with a pulsed generator, such as rehabilitation centers employ in treatment of chronic pain. Desensitization can be obtained with liniments and ointments, mustard packs or plasters.

Even animal surgery has been performed using counterirritation, e.g., the “twitch” on the nose of horses. Finally, it is helpful to understand some of the common injectable anesthetics that are used locally for the relief of pain. These are used both in dental and surgical care. But they have some side effects and potential allergic reactions.

Injectable narcotics should always be avoided, as they leave behind serious effects on the brain. They are not only difficult to metabolize, but because of their tendency to produce euphoria can become rapidly addicting. On rare occasions for major procedures, general anesthesia may be necessary.

The gaseous agent used in these cases should be that which is most rapidly metabolized and least toxic to the system. Nitrous oxide and oxygen are commonly employed together to relieve mild pain. Although ether is quite flammable, it still remains the safest form of general anesthesia, due to its rapid clearing from the blood by the way of the lungs and relatively low toxicity to the liver and other organs.

Open drop techniques in a well ventilated area can be used, but for safety reasons general anesthesia ideally should be performed in a hospital. Newer anesthetic agents (Halothane, Ethrane, etc.), although more likely to cause toxicity, are less dangerous to the heart and usually nonflammable. Regional blocks, local nerve blocks, and spinal anesthesia have their places in hospital settings.

Suturing

Considerable practice is required to suture incisions and lacerations quickly and accurately. Yet these skills are not beyond the reach of the average layman gifted with manual dexterity or an interest in mastering the art. If possible, practice your suturing techniques on a piece of sponge rubber, upholstery, or even a pillow.

Some surgeons become skilled in knot tying, practicing on door handles or in the automobile while traveling. The accompanying diagrams, located on pages 178 to 189, help demonstrate the principles of the three basic methods of surgical knot tying. The one described as an “instrument tie” utilizes a hemostat or needle holder, while the others require only skillful fingers for proper use.

I would suggest that a novice begin with the two-handed tie and instrument tie, adding more complex forms as skill is gained. Avoid tying the sutures so tightly that insufficient blood flow to the skin edges results. This would cause delayed and incomplete healing of the wound. “Approximate, don’t strangulate” is the watch word for closure of lacerations with sutures.

There are certain injuries that are never sutured. Human bites, animal bites, and lacerations opened longer than 12 hours, or those grossly contaminated are not sutured, but allowed to granulate and heal by secondary intention. In a home-like setting it is possible to make the appropriate needles, like bending a sewing needle, sharpening the point in a chisel fashion to better penetrate the skin.

Silk or cotton can be boiled along with the needle, thus sterilizing it for use in suturing. Prepared packages, that come already sterile, are available from suture manufacturing companies and can be obtained in various sizes and needle styles. Remember to consult the suture use manual for aid in selecting the appropriate sutures.

Biopsies

The removal of a tissue for accurate pathologic diagnosis is called biopsy. If the lesion is large and only a small part is to be removed, the surgery is called an incisional biopsy. Usually a small portion of normal adjacent skin is excised with the lump under question. When it is possible to completely remove the growth and obtain a margin of normal tissue around it, the procedure is termed an excisional biopsy.

These are very useful procedures, not only for the diagnosis and treatment of blemishes and abnormal growths of the skin, but also for lumps beneath the skin in accessible organs, such as the breast. A breast biopsy can often be performed without general anesthesia or hospitalization when the surgical skills are present and the necessity for tissue diagnosis exists.

More commonly, skin biopsies are used to determine the presence or absence of cancer and to excise unsightly or irritating growths that have developed in areas amenable to their removal. On certain parts of the face, such as the alar portion of the nose, the lips, and ears it may be necessary to cover the removed skin with a graft.

“Split thickness” skin grafts can utilize a very thin membrane of excised skin that matches in color and texture the area requiring the covering. Specialized plastic surgery procedures under local anesthesia can at times be used to enhance the cosmetic results of these operations. The technique of a skin biopsy utilizes an elliptical incision with the ends pointed to permit easier closure.

The incision is made perpendicular to the plane of the skin to avoid bevel edges that will increase scarring of produce puckering when the wound is closed. “Undermining” the edges with blunt dissection will enable the skin areas to come together without undue tension and permit suturing with the least likelihood of wound separation.

When malignancy is suspected, the margins should be wide enough to prevent possible early penetration of them with abnormal cells, and thus prevent the necessity of a second operation. Appropriate spacing of sutures and their removal in as short a time as wound healing will allow will minimize scarring and improve the cosmetic result of these surgical procedures.