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I presume that all wounded vessels, of a size such that the blood-pressure would force blood out of them in spite of the buried sutures, have been carefully secured, and that the wound is thoroughly aseptic.
2 The sutured muscles and aponeuroses are eventually perfectly restored as regards function, as also is the deep fascia. Even the deep fascia has important functions, especially in certain localities, and in connection with the following points.
3. Deep, rougli and depressed cicatrices are avoided.
To dweli for a moment or two on the history of the subject (before illustrating its practical application by a description of my own experience), it has first of all to be confessed that this, like other important developments of antiseptic surgery, has attracted much attention in Germany There it appears to have originated in the practice of Werth, the gynæcologist, who praised these sutures highly, as tending to success in operations for ruptured perinæum. It is, however, Esmarch's assistant, Neuber, (the inventor of decalcified bone drainage-tubes) and Professor Kuster, who are the chief apostles and pioneers of this great advance in surgery, for such I esteem it. It was a pamphlet by the former, giving an account of the amputations done at Kiel during the last year, which first called my own attention to the matter.
Neuber has worked out the subject thoroughly, more especially in a pamphlet entitled Vorschlage zur Beseitigung fur alle frischen Wunden (Lipsius and Fischer, Kiel, 1884).
Kuster read his paper at the last meeting of the Society of German surgeons. In the discussion which followed, Esmarch having stated
. with these sunk sutures, drainage-tubes could be altogether dispensed with, he was asked, “What, after excision of the hip?" He thereupon answered, shortly and decisively, “Yes."
Turning to my own experience, which, though sufficiently varied, is small as compared with that upon which Neuber, Kuster and Esmarch based their assertions, I have carefully recorded the details of two amputations of the thigh, and one of the leg, two excisions of the hip, one case of evidement of the bones of the knee-joint, one wedge-osteotomy of the hip, one osteotomy of the tibia and fibula, one operation for ununited fracture of the same bones, two suturings of fractured patellæ, one removal of sequestrum in necrosis, of the symphysis pubis, with large abscess in the abdominal wall; one operation for congenital contraction of the knee by open antiseptic incision, one incision to examine a chronic swelling of the perotid, one excision of the multiple sebaceous glands of the
head, and two cases of resection of the quadriceps extensor cruris. In all these seventeen cases, except two, the buried sutures have done all which sanguine hopes could expect of them. But, in stating this, I must confess that I have not always dared to dispense with drainage-tubes. I simply thought I ought to feel my way cautiously. Of the two cases which I have mentioned as being exceptions, one was an almost hopeless case of amputation of the thigh in an old lady, over 70, who suffered from sloughing of almost all the soft parts of one of the lower extremity, from the knee downwards, with burrowing of pus up to the hip, the cause being erysipelas. She died forty-eight hours after the operation. The remaining case possibly casts a slur upon buried sutures, or upon their employment in my hands. A man, aged thirty, with advanced strumous disease of the knee tuberculous disease of both legs, and hectic fever, had the knee freely excised, and all the diseased synoval tissues removed with scissors and sharp spoons. The bones were then fixed firmly together with silver sutures, and the wounded soft parts secured with buried sutures. His only hope could lie in speedy osseous union. Unfor. tunately, the edges of the flap sloughed. Thus, frequent changes of dressing, with consequent slight disturbances of the ends of the bone, were necessitated. Finally, our efforts to keep the wound aseptic failed, and amputation was performed. I think it possible that my covered sutures had seriously interfered with the imperfect blood-supply in this poor enfeebled creature.
I will describe briefly two or three of the above cases and their results. In amputating the leg two lateral and very short rounded skinflaps were made. A very short distance (about half an inch) above the angles of junction of the skin-flaps, the muscles were divided by a circu
The periosteum was divided nearly as low down as the muscles, and turned back up to the level where the bones were divided. The periosteum must be reflected to an eigth of an inch or more beyond the point of division of the bone, and carefully held out of the way, without being stripped further up, while the saw is being used. Next, the vessels are tied until it is time to put in the sutures. About three or four will draw the periosteum securely over the cut surfaces of each bone, leaving a small opening opposite the medulla. Next, the muscles and aponeuroses of the extensor side are united to those of the flexor side, more or less en masse, by five or six sutures of strong catgut. These sutures had better not, as a rule, be made to go quite through to the deep surfaces of these structures, but should be half an inch to one inch from the cut edges at the superficial surface. The bones are thus completely covered. Next, the deep fascia should be separately sutured, and lastly the skin,
Almost the first time I ever tried buried sutures was in an amputation of the leg (middle third) done in February, 1884, in the West London Hospital. The flaps, when thus sewn up, were too tight to allow room for a drainage-tube to be inserted without violence. Therefore none was used, except one of very small size passed through one corner of the skin incision, but not into the depth of the wound. This case was further complicated by the fact that, owing to an unhealthy condition of the marrow, the medulla of both tibia and fibula was scraped out right up to the upper epiphyses of those bones ; and the medullary cavities, thus emptied, were injected with liquor hydrargyri perchloridi (whose strength, it may be remembered, is just over 1 in 1,000).
Healing took place throughout by the first intention, except as regards the skin, which gaped a little when its sutures gave way. However, the muscles, and doubtless the periosteal sutures held on; and the edges of skin soon, as it were, crept together again. The temperature rose on several days to 101°, and then gradually sank to normal on the tenth day. There it remained, except that, once or twice during the next month it rose to 102°, for no reason in any way connected with the stump, as far as could be made out. The patient has long been quite convalescent, and is using an artificial leg.
After the excisions, the wedge-osteotomies and the suturing of the patellæ, the excellent results, as regards freedom of the skin-cicatrix from cicatricial anchorage to the bone, were very manifest. They contrasted strongly with the deep valleys which soon follow incisions for resection, when sutured in the ordinary way. This good effect is, of course, particularly valuable in the face.
Resection of the quadriceps extensor for infantile paralysis, with loose knee, would not be justifiable without the use of buried sutures. Concerning the ultimate result of these cases, there has not been time yet to judge ; but in each of my cases I have succeeded in shortening the muscle an inch an a half, with rapid healing of the wound by first intention, no deformity or depression, and merely a longitudinal, linear, undepressed cutaneous scar. No drainage-tubes was used.
The large abscess-cavity in connection with the necrosed symphysis pubis extended outwards as far as the iliac crest, and was nearly as wide. It was supposed, when sent to me, to be an inguinal hernia. I slit it up, scraped out its lining thoroughly, and closed it in with sutures which passed from side to side beneath its floor, but not through the skin ; it was thus reduced to a long, narrow and shallow groove. This I closed with superficial sutures. The deep sutures held on till the depth of the cavity was obliterated by the healing process. At the lowest angle of the wound, a drainage-tube was passed straight down to the small cavity from which the necrosed symphysis had been extracted.
In no cases have I found these sutures more brilliantly successful than in dealing with sebaceous cysts of the head. Having dissected out three from the scalp of the gentleman, I obliterated the remaining cavities by two buried sutures in each, passing them well beneath the floor of each small wound. No cutaneous sutures were used at all; ihe skin. wounds did not gape.
Over the wounds was placed a coat of salicylic acid dissolved in ether, as well as a little powdered salicylic acid. No bandages were used. The patient went daily to his work at Summerset House, attended a garden party in the meanwhile, and, a fortnight afterwards washed the salicylic scab, as it might be called, or three sound linear cicatrices. It is important to say that he was not allowed to brush his hair during the treatment; it was kept both tidy and aseptic by occasionally sponging with a wash containing spirit, sublimate and rosewater.
In conclusion, I have to say that it is only in strictly antiseptic surgery I would venture to recommend these sutures; but that, in the case of all surgeons who have faith in antiseptic theory and practice, they will find in buried sutures an effective and beautitul addition to their methods.
PHOSPHOROUS NECROSIS OF THE JAWS.*
That phosphorous necrosis of the jaws is a local expression of the constitutional condition produced by the inhalation of the vapor of phosphorous and by particles of the agent taken into the system with the food by the operatives in match factories, who do not give proper attention to the cleanliness of the hands.
That the introduction of the agent into the system is, as a rule, very gradual, and in such small quantities as to avoid the production of syi ms of acute poisoning. That in this way the chronic toxic condition of the system is induced, characterized chiefly by disintegration of the red blood corpuscles and fatty degeneration of the arterial coats.
*Conclusions from a Paper read at the Annual Meeting of the American Surgical Association, April 24th, 1885.
3. That the toxic condition precedes the development, is shown by the fact that the disease does not attack operatives recently exposed to the action of the agent, but those who have been exposed for a period of years. 4.
That examinations of teeth of operatives have shown that many who have a condition of caries, and that many who have returned to work immediately after the extraction of teeth, have enjoyed immunity from the disease, showing that the agent has not attacked the periosteal tissue thus exposed. (In one case, the disease did not appear until three months after labor in the factory had ceased.)
5 That individuals vary in their susceptibility to the action of the poison ; for this reason many suffer immediately with symptoms of acute toxic conditions, such as nausea, vomiting, etc., and are compeiled to abandon work in the factories.
6. That the conditions under which experiments have been made on animals to prove the absence of the disease until exposure of the periosteum and peri-alveolar tissue was affected, were not similar to those to which operatives in match factories are subjected.
7. That treatment of the disease in the primary stage in the manner outlined, is efficient and prevents its progress.
8. That the antidotal powers of turpentine have been established, both in neutralizing the effects of the poison upon operatives during their work, and also in the treatment of the early stage of the disease.
9. That the disease is to be prevented among operatives by the adoption of thorough methods of ventilation, stringent rules with regard to cleanliness, and the free disengagement of the vapor of turpentine in all the apartments of factories in which the fumes of phosphorus escape.
REPORT ON DISEASE OF THE NERVOUS SYSTEM.
BY DR. W. C. PEASLEE.
DIPSOMANIA.-M. Le Dr. M. V. Magnan, (Alienist and Neurologist No. 2, April, 1885), says the alcoholic excitement with which an attaek of dipsomania terminates should not be confounded with the dipsomania itself as it is a complication only, not a symptom of it. Dipsomaniacs "are patients who become intoxicated whenever their attacks come on." The chief and characteristic feature of which is to manifest itself in intermittent and paroxyismal attacks, followed by great cerebral discomfort, which gradually diminishes, the patient becoming sober and regret
* Translated by Henry R. Stedman, M. 1)., Boston.