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Three sizes of twisted silk are used for suture and ligature: heavy silk for ligature of the large arteries; medium silk for ligature of smaller vessels and for various suturing in the abdomen; fine silk for peritoneal and intestinal

suture.

LENTZ&SONS

FIG. 194.-Pedicle-needle.

The silk should be as small as is consistent with secure ligature. The heavy silk is necessary for the ligature of pedicles in which a large amount of surrounding tissue is included with the artery.

FIG. 195.-Small curved trocar.

The silk is rolled on glass spools or on cores of gauze, contained in glass tubes plugged with cotton, and is then sterilized in the steam sterilizer by fractional sterilization. It is advisable always to use, for heavy ligature,

FIG. 196.-Large cyst-trocar.

silk of a uniform size, because the operator becomes accustomed to the strength of the silk and knows just how much strain it will bear. Silkworm-gut is the best material to use for suture of the abdominal incision in

case the "through-and-through" or interrupted masssuture is employed.

The silkworm-gut should be of the heaviest and the longest size. It may be sterilized by boiling with the instruments before the operation.

FIG. 197.-Reiner's needle-holder.

LENTZ&SONS

Catgut is sometimes employed for ligature and suture. The difficulty of securing certain sterilization makes it advisable to avoid using this material within the peritoneal cavity. Sterilized silk is so certainly absorbed in all cases and is so easily employed that the writer has altogether given up the use of catgut within the peritoneum. It is useful as a buried suture for the muscle and fascia of the abdominal wall. Silk is not so certainly absorbed in this position, and if the catgut should happen to be imperfectly sterilized, no worse result than suppuration of the incision will occur.

Various methods of sterilizing catgut have been introduced. The writer uses the following method, which bacteriological experiments and clinical experience have shown to be good: The catgut is soaked in juniper oil for one week. The oil is then washed out with ether and the catgut is soaked in ether for forty-eight hours. The gut is then rolled on glass spools and is placed in a glass jar containing pure alcohol. The alcohol is boiled in the jar for an hour at a time on several successive days. The gut is used directly from this jar, and is always boiled in the alcohol for an hour before each operation. In this way, if a considerable amount of gut is prepared at one time, it is subjected to many boilings before it is used up. The alcohol is boiled by placing the glass jar in a vessel of hot water.

The following methods of sterilizing catgut are also good:

Reverdin's Dry-heat Method for the Sterilization of Catgut.-Soak in ether for one or two days. Change the ether once. Dry' and roll on glass reels, place in testtubes covered with cotton, and place the tubes in dry-air oven. In order not to burn or render the catgut too friable, the temperature should be very slowly elevatedat least one hour before reaching 100° C., and one hour and a half before reaching 150° C. This temperature should be maintained for two hours; then the catgut

is slowly allowed to cool in the oven. Eight or nine hours afterward the operation must be repeated; the gut is then allowed to soak for twenty-four hours in oil of juniper-wood, and is then kept in absolute alcohol.

The Cumol Method for the Sterilization of Catgut, employed at the Johns Hopkins Hospital.-1. Cut the catgut into the desired lengths, and roll 12 strands in a figureof-8 form, so that it may be slipped into a large test-tube. 2. Bring the catgut gradually up to a temperature of 80° C., and hold it at this point for one hour.

3. Place the catgut in cumol, which must not be above a temperature of 100° C., and hold it at this point for one hour.

4. Pour off the cumol, and either allow the heat of the sand-bath to dry the catgut, or transfer it to a hot-air oven, at a temperature of 100° C. for two hours.

5. Transfer the rings with sterile forceps to test-tubes previously sterilized as in the laboratory.

The cleanest specimens of the crude catgut should be obtained for surgical purposes. There is no doubt that some specimens of crude catgut are more difficult to sterilize than others.

The writer uses catgut only for suture of the abdominal fascia and muscles. Large-sized gut is employed. The Dressing.-The dressing of the abdominal wound. consists of ten or twelve layers of sterilized gauze, covered by a large sterilized abdominal pad about 1 inch

thick, 13 inches long, and 9 inches broad. The pad is made of absorbent cotton enclosed in a layer of gauze. The dressing is retained in place by a six-tailed sterilized abdominal binder of flannel.

If no drainage through the abdominal incision is employed, the use of celloidin with the gauze dressing is of advantage. It retains the dressing securely in position for an indefinite period, and, if used liberally, it acts as a splint for the abdominal wall. Either of the two following formulæ given by Robb may be used:

R. Ether (Squibb's),

Absolute alcohol,

Of a solution made of 15 grains of

bichloride crystals dissolved in 11
drams of absolute alcohol,

ää. 3viss;

mxvj.

Mix, and add of Anthony's "snowy cotton" enough to give the solution the consistence of simple syrup.

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Mix, and add of Anthony's snowy cotton" enough to give the solution the consistence of simple syrup.

The celloidin should be poured over the edges of the first layers of gauze that are placed upon the wound.

CHAPTER XL.

THE TECHNIQUE OF GYNECOLOGICAL OPERATIONS (Continued).

Abdominal Drainage.-Drainage of the peritoneum. is accomplished by means of the glass drainage-tube (Fig. 198), or by capillary drainage with gauze. The perito

FIG. 198.-Glass drainage-tube.

neum may be drained through the abdominal incision or through the vagina. On account of the difficulty of keeping the vagina sterile, drainage through the abdominal incision is the safer method. Vaginal drainage is. preferred when the operation is performed through the vagina and no abdominal incision is made, as in the operation of vaginal hysterectomy.

The glass drainage-tubes should be of various lengths -5 to 7 inches. The outer diameter should be about 3g or 1⁄2 inch. The lower portion of the tube is perforated with small holes over a distance of about 11⁄2 inches. Around the upper part or neck of the tube, which protrudes from the abdomen, is placed a square of rubber dam, such as is used by dentists, about 8 by 8 inches in size. The tube passes through a hole in the center of the rubber. The tube and the rubber dam may be sterilized by boiling. The tube is usually placed in the lower angle of the abdominal incision, and the abdominal dressing is split so that it may be placed around the tube. The bandage is applied so that the four upper tails pass above the tube and the two lower tails pass below it. The

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