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spaces may be overlooked and left unremedied. The direction of an incision is often a material factor, for the apposition of tensile structures largely depends upon whether they have been merely separated or divided. Before all these considerations, however, is the surgical cleansing of the site of operation, the hands of the surgeon and all assistants, and every article brought into use. In preparing the site of operation it is not essential that the Lister method be adhered to. In fact the strong carbolic acid solutions, the antiseptic spray and iodoformizations may be toxic to both patient and operators. Without describing the many methods now in vogue for securing asepsis, or even going into detail in any particular, it may be said that a full bath, shaving the site of operation, a soap poultice, thorough washing with soap and water, liberal use of safe germicidal solutions, and ether or alcohol combine the most practicable means for treating the skin of the patient, while the hands of the operators are best prepared by cutting and cleaning of the nails, washing in soap and warm water, applying chloride of lime and carbonate of soda in the form of a paste, immersion in an antiseptic solution and the wearing of sterile gloves. These precautions having been anxiously observed, the final result may be considered to depend upon later contingencies.
Before closing the wound at the end of an operation, all hemorrhage should be stopped. In fact, whenever it be possible, loss of blood should be forestalled. In securing these results, however, the vulnerability of all living tissues should not be forgotten. Unnecessary and promiscuous compression by hemostatic forceps is to be avoided. Let the ligatures be only sufficient for the purpose and their size be as small as shall be compatible with their function. Sponging is to be done by gentle pressure rather than by rubbing or wiping a wound. Disregard of these details will cause a wanton destruction of tissues and sometimes unexpectedly put a forfeit upon the final result.
If, perchance, hemorrhage shall continue or begin afresh after the wound has been closed, even though it be not sufficient to cause shock, wound structures will be separated and the possibilities of sepsis multiplied. In such conditions, unless asepsis be absolute, drainage will be required. This artificial excretory channel is a necessity also whenever the wound tissues are bruised, diseased or infected. The growing tendency is to avoid drainage, but under the circumstances mentioned it becomes a necessary evil, or at least a choice of two evils. So essential is it in some instances that life depends upon it. Physiologic elimination having become impossible or inefficient, in the absence of artficial aid the blood soon becomes loaded with the products of disease.
The choice of drainage materials will depend upon the character of the wound and the skill of the surgeon. Larger drainage is needed for deeper wounds than for those more superficial. Perforated glass and rubber tubing are standard. It is of advantage often to induce capillary action through these, which may be done by means of gauze, or by fashioning a Mikulicz's drain. For superficial drainage gauze, silkworm gut, catgut and horsehair are usually sufficient. Whatever material be used, it should be removed at the earliest possible moment.
The suture materials in most common use are silk, silkworm gut, catgut, kangaroo tendon, ox tendon, horsehair and silver or steel wire. Although wire is the only inorganic suture among them, catgut is practically the only absorbable one. When chromicized, catgut is a very good substitute for kangaroo tendon and ox tendon. Silk, silkworm gut, horsehair and wire are sterilized hy boiling in water for an hour, and may be kept safely in strong alcohol or in five per cent solution of carbolic acid and water. The preparation of catgut has been a sore trial for many surgeons for years but now several very satisfactory methods have been sought out, among which are Van Horn's and those described by Senn and Ochsner. The last named is simple and is thus described:
"Catgut is prepared by immersing in sulphuric ether for one month, then for one month in strong commercial alcohol, in which one grain of corrosive sublimate to the ounce has been dissolved, the solution being renewed once during this time. It is then preserved indefinitely in a solution of one part of iodoform, five parts of ether and fourteen parts of strong commercial alcohol. This catgut will last seven to ten days in tissues, according to the size used.”
For use in suturing bones and in hernias a chromicized catgut is recommended, prepared as follows:
“The catgut is immersed in ether for one month, then in a solution prepared in the following manner: Take: A. Chromic acid
.5 parts Take Solution B and soak therein catgut for forty-eight to ninetysix hours, according to resistance wanted. Forty-eight hours will resist absorption by tissue for fifteen days; ninety-six hours will resist for thirty days.
C. Take catgut out of Solution B, rinse quickly in sterilized water to free it from Solution B, stretch and rub quickly with a hard, sterile towel to remove any of the Solution B which may still be adhering to it, wind on rods or slides at least three inches in length, and preserve indefinitely in the following solution: D. Carbolic acid, ninety-five per cent.
5 parts The catgut may remain in this solution for many months without depreciating in quality, or it may be kept for an indefinite period of time in the same solution as plain catgut.”
The so-called catgut infection is ascribed by Ochsner to one of five conditions, namely: "(1) commercial catgut which may not be reliable; (2) catgut that has been saturated with antiseptic substances which cause a necrosis of the tissues included in the suture or ligature; (3) pressure necrosis due to tying the stitches too tightly; (4) infection of the catgut by careless manipulation by the surgeon or his assistants, the suture or ligature being permitted to touch objects not sterile; (5) infection of the catgut by the septic hands of the surgeon or his assistants."
Silkworm gut possesses the most desirable qualities of a suture for external wounds and is therefore a great favorite. It is small in size, smooth, easily sterilized and durable. It may be applied either continuously or interruptedly. Horsehair possesses similar qualities, but its use is more limited to facial wounds. Silver wire is especially adapted to sustain great strain, but even in this class of cases may be substituted by silkworm gut.
The characters of needles are seldom commented upon as thoug! they were of little consequence. Without dilating upon this subject the plain statement may be made that whenever possible the round, sharppointed needle should be used. In practice it is applicable to serous structures, while a flat needle with slightly cutting edges is better suited to the integument. Needles having three sharp edges cause more bleeding, and form large gaping wounds that tend to tear still more. Straight needles are adapted to plain surfaces, while curved ones are better used in cavities and depressed tissues. Inasmuch as smaller and shorter needles may in general be inserted by the aid of needle holders, their adoption is to be recoinmended.
The methods of applying sutures are various and well known. While much depends upon the skill of the surgeon, there are real advantages belonging to the different forms. A wound may perhaps be closed more quickly by continuous than by interrupted sutures, but the former do not permit of the establishment of drainage so well as the latter and the wound will gape through its whole extent if the continuity be broken at any point. The interrupted suture is more generally applicable than any other form. The chief points to be decided are the needs of buried and relaxation sutures. In operations through a thick tissue wall it is very important to avoid dead spaces. Buried sutures are calculated to accomplish this very purpose by bringing corresponding structures into accurate apposition. If the incision involves the peritoneal cavity, the danger of hernia may at the same time be lessened, since the amount of scar tissue is thereby diminished. It is a principle in the art of surgery, however, that as little as possible of foreign material should be left within the tissues, and especially within constricted tissues. Except for this, buried sutures might be universally adopted. If as much care be used in the insertion of through and through inter rupted sutures as in buried work, we believe the same results might be obtained with removable material. The principle conceives of a suture including relatively much more muscular than skin and serous structures, each layer of muscles being brought into close approximation. In diagram this suture has a circular rather than a rectangular form. The relaxation suture is almost paradoxical in its actions. It does relax superficial structures but at the same time firmly grasps those deeper in the wound. In adopting this form of suture it will usually be necessary to add another layer to coapt the integument. Whichever form or method be adopted, except as modified by drainage, it is more important to make close approximation of deeper than of superficial tissues. In tying them the nutrition of the constricted tissues must not be cut off.
Partial closure of wounds may be effected by adhesive plaster overlying the dressings and adhering to the integument on either side of the wound. Adhesive plaster and bandages may also be made use of for purposes of wound-closing by compression. It is apparent that, if for any reason, the wound needs to be inspected or redressed removal of the dressing will permit the wound to gape. In general it may be said that except to hold in place the outermost dressings and bandages, the use of adhesive plaster is not calculated to promote the aseptic treatment of wounds.
When an operation has been performed according to the principles indicated in the foregoing and the wound edges have been accurately coapted, the outer dressings need be little more than a simple protective against the impurities of the atmosphere and of those things with which the site of operation might come into contact. For this purpose sterile gauze is amply sufficient. If, however, there be raw surface or a portion of the wound not covered by integument, the most satisfactory artificial, according to my experience, is gutta-percha tissue laid on in narrow strips. This material does not adhere to and destroy the fine granulation tissue cells and will allow the wound secretions to be gathered and absorbed by the superimposed dressings. Collodion is applicable to clean wounds that need no other covering.
THE TREATMENT OF APPENDICITIS.
BY JOHN T. BIRD, M. D., CLARKSTON, MICHIGAN.
LATE PHYSICIAN TO THE MICHIGAN REFORMATORY AT JONIA.
ACCORDING to some there are three views of the profession on this subject: (1) Exclusive surgical, (2) exclusive medical, (3) medical treatment, as a rule, surgical treatment of cases in which the indications for an operation are clear.
The fact that from eighty to ninety per cent of all cases of acute appendicitis recover with judicious medical treatment, is proof against our extremists' idea that all cases should be operated on during the first twenty-four hours. Then, too, the loss of ten cases in each one hundred is equally convincing that some cases require more treatment than any physician alone can give. Therefore I am a firm believer in the plan outlined in the last method, or the mixed treatment. Just when the case ceases to be medical and enters the surgical domain is a very important point and one calling for much common sense and sound judgment.
In the beginning of an acute attack I always insist on complete rest in bed, clear the intestinal tract of all foreign material by a mild cathartic-magnesium sulphate in one drachm doses, well diluted, every half hour until four doses have been taken, when, if not effectual, I give a small enema of soap and water with the addition of one drachm of turpentine if there is much tympanites during the first twenty-four to thirtysix hours. I administer nothing by the stomach except what water the patient desires. At the outset I am in the habit of applying the ice-bag to McBurney's point and continuing it until all symptoms of the disease have subsided. Some authors recommend heat instead, among them W. F. McNutt, of the University of California. This treatment always seemed to me to be contraindicated for we know that heat increases the tendency to suppuration and aids the growth of bacteria, while on the other hand ice decreases both of these. Great care should be given to diet, which must be liquid, giving only those things which leave the least residue. In extreme cases only does it ever become necessary to resort to morphin or opium, for while relieving pain they produce symptoms so marked that the gravest conditions develop, and we lose our patient through overkindness. The ice is a very good substitute for those narcotics for the relief of pain.
The questions of surroundings, location, and the opportunity of securing skilled surgeons should be very thoroughly considered before an operation is advised, for in unskilled hands and with unclean instruments the patient's chances are better for recovery with only the internal septic material to fight against than to have added that from without by a tyro. Nature is very kind and with some assistance and no hindrances on our part, I feel that more patients will be saved than by entire surgical means.
During my term of service in the Michigan Reformatory, I have treated along the plan outlined quite a number of cases of acute appendicitis, none of which have had recurrent attacks while under institutional care, but when the time of service is taken into account, some allowances should be made for no recurrences. The average temperature at the outset was 99.3°, pulse 100, both increasing until the end of the third day, when the temperature was 103° and the pulse 120, receding at about the end of the tenth day and becoming normal at the end of the second to third week. Some recommend that if the temperature and pulse (especially the latter) increase the second and third day, it is a case for the surgeon, but this has not been my experience, although my chance for observation has been limited.
Synıs, in the New York Medical Journal of May 15, 1897, outlines the following expectant treatment, which is about the same as I have given and which has served me so well: Put the patient into bed and keep him there; apply over the whole iliac region a soap "poultice,"