Page images
PDF
EPUB

opposite directions, and the two ends then fastened with the continuous turns of the circular bandage. In longitudinal wounds of the extremities a circular bandage is employed, which is divided at one end into heads, an inch broad, and, at a proper distance, according to the thickness of the limb, is furnished with slits. The middle of the bandage is to be placed on the side of the limb opposite to the wound, both ends are to be brought towards the wound, the heads drawn through the slits, and properly carried on in circular turns, and in opposite directions.

If the bandage be to act, specially, on the bottom of the wound, a graduated compress must be applied on both sides, and the bandages drawn together upon them. The influence of the uniting bandages is never to be too much relied on, as the linen always, more or less, yields, and gets displaced. Therefore bandages, when the union of the wound is effected by other means, are applied only to assist the union, prevent the retraction of the parts, and so on. An expulsive bandage, in many cases, answers

the same object; for instance, in amputations.

[As to the use of bandages in wounds, I must confess I am no advocate for them unless they are absolutely necessary to prevent the parts dragging asunder, and then only the least possible quantity should be employed. A simple spiral bandage carried once over the wound, and extending a little above and far below it, if from the pressure on the superficial veins there be tendency to serous effusion in the cellular tissue, or a many-tailed bandage is amply sufficient. A quantity of bandage of many thicknesses as used even within my recollection is very detrimental, as heating the part and tending to promote suppuration, which it is desirable to avoid.-J. F. S.]

a

312. Sticking Plaster, (Heftplaster, Germ.; Agglutinatifs, Fr.,) which is most especially employed as a means of closing wounds, operates more certainly than the bandage. When the surface of the wound has been properly dried, and the parts brought into suitable position; the one end of the sticking plaster is to be applied at sufficient distance from, and on one side of the wound, to be held fast there, and when the edges of the wound are brought into the closest contact, the other end is to be drawn across them, and pressed down on the other side. The first piece of plaster is to be laid upon the middle of the wound, and then as many on both sides as will bring the edges in perfect union, and cover the wound itself uniformly. In longitudinal wounds of the limbs, the middle of the plaster may be laid directly opposite to the wound, and the two ends may be brought towards the wound, the one passing through a cleft in the other, crossing upon, and thus uniting, the wound. If the sticking plaster is to be applied on a part covered with hair, the part should be first shaved. making the sticking plaster, the emp. adhesiv. should be spread not too thick, but sufficiently so, upon strong linen. In small superficial wounds English sticking plaster (court-plaster) answers the purpose.

In

[The old surgeons, though mostly relying on bandages and sutures, employed a sort of sticking plaster, though differing from the kind now used; thus THOMAS Gale, when describing "briefely the cure of a simple and small wounde, where the skynne onely is divided or cut," says:-"You shall aptly ioyne the lippes or sides of the wounde together, so euen as possible you can: then make a stufe wythe towe and the whyte of an egge mixed with a little salte, and apply it to the wounde, then roll and bynde it accordyng to arte, and this is sufficient in such kynde of woundes. You must also commaunde the Pacient that he exercise not the wounded member, least that he causeth accidentes to falle to the wounde, as inflamation, fluxe of humours, dolour, and payne, &c. ***If the wounde be great in the fleshe, and yet without accidents, you shall beginne your cure as in the chapter before, (the previous paragraph,) that is, by comprisyng and ioyning the sydes of the wounde together, and then rollynge and byndyng it. But if the wounde be bigge, wyde, or els ouerthwarte the member, so that rollinge and binding are not sufficient: than you are compelled to use stiching, of which there be diuers

sortes, and I wyll set oute those whiche are moste in use. But or you goe aboute the stitching of the wounde, geue diligent heede that it be mundified and made cleane, that there remayne not in it eyther any uncleannesse, as heare, duste, oyle, or such lyke: whiche may hynder the adglutination of the wounde.” (p. 2.)

"A piece of sticking plaster," says JOHN HUNTER, "which has been called the dry suture, is more general in its application than the uniting bandage, and is therefore preferable to it on many occasions. I can hardly suppose a wound, in any situation, where it may not be applied, excepting penetrating wounds, where we wish the inner portion of the wound to be closed equally with the outer, as in the case of hare-lip. But even in such wounds, if the parts are thick and the wound not large, the sides will seldom recede so far as to make any other means necessary. The dry suture has an advantage over stitches, by bringing a larger surface of the wound together, by not inflaming the parts to which it is applied, and by neither producing in them suppuration or ulceration, which stitches always do. When parts, therefore, can be brought together, and especially where some force is required for that purpose, from the skin not being in large quantity, the sticking plaster is certainly the best application *** The sticking plasters should be laid on in strips, and these should be at small distances from each other, viz., about a quarter of an inch at most, if the part requires close confinement; but when it does not, they may be at great distances. This precaution becomes more necessary if the bleeding is not quite stopped; there should be passages left for the exit of blood, as its accumulation might prevent the union, although this does not always happen. If any extraneous body, such as a ligature, should have been left in the wound, suppuration will take place, and the matter should be allowed to vent at some of those openings or spaces between the slips of plaster. I have known a very considerable abscess formed in consequence of this precaution being neglected, by which the whole of the recently united parts has been separated." (pp. 209, 10.)

Our common hospital sticking plaster is the soap plaster of the London Pharmacopeia, with a little resin to render it more adherent, spread on stout calico. I prefer it, however, without the resin, as less likely to cause irritation, and the plaster is quite sticky enough if fresh spread. TYRRELL was accustomed to use equal parts of soap plaster and compound frankincense plaster, but I do not know that it possesses any superiority over the soap plaster, except in having a more agreeable smell. LISTON (a) prefers a transparent plaster, consisting of a solution of isinglass, spread on the unglazed side of silk, which, when used, requires a hot moist sponge to be run quickly over it, so as to melt the isinglass and render it sticky. "This composition," he says" becomes sufficiently adherent; it keeps its hold often to the end of the cure; and it is quite unirritating. Being transparent, the plaster does not prevent any untoward process that may be going on underneath from being observed, and, if any fluid collects, an opening can be snipped for its escape." (p. 33.) I have used this isinglass plaster several times, but do not find it has any material preference over the common adhesive. It is not a new invention, but has been long since used in Germany, where it is called English plaster, and is really no other than our common court-plaster spread on white silk.-J. F. S.]

313. Stitching, or Suture, (Sutura, Lat.; Naht, Germ.; Suture, Fr.,) which was anciently so much in use, and at a later period has been entirely discarded by many Surgeons, is always accompanied with a considerable irritation of the wound. Inflammation, and retraction are often excited to such degree by the presence of the threads, that the adhesive process cannot be perfected, and suppuration takes place. However much these reasons may limit the use of the suture, yet in the following instances it is necessary-1. In widely-gaping wounds of the face, in which it is desirable to produce very close union, especially if the salivary duct be injured, or the lips perfectly divided. 2. In transverse cuts in such parts as have great disposition to retract. 3. In deep transverse wounds of the tongue. 4. In wounds with large flaps. 5. In large penetrating wounds of the belly. 6. In wounds of parts whose peculiar structure admits no other union, as clefts of the ears and eye-lids. 7. In complete tearing through of the perinæum during difficult labour.

[JOHN HUNTER was certainly no advocate for the use of sutures, for he observes :— "The interrupted suture, which has generally been recommended in large wounds, is

(a) Practical Surgery.

still in use, but seldom proves equal to the intention. This we may reckon to be the only one that deserves the name of suture; it was formerly used, but is now in a great measure laid aside in practice, not from the impropriety of uniting parts by this process, but from the ineffectual mode of attempting it." (p. 210.)

The use of sutures to retain the edges of a wound together, and thereby encourage the process of adhesion, is still a matter of dispute among Surgeons; some employing them on every occasion, and others never using them at all; some considering that they are very powerful auxiliaries in uniting a wound, and others that they are objectionable as oftentimes exciting constitutional irritation, and thereby disturbing or preventing the adhesive process. The real, though generally overlooked, ground of objection to them is their indiscriminate use, both as to the condition of the parts on which they are applied, and the length of time they are left after having been introduced.

Sutures are commonly employed "in those parts of the body," to use HUNTER'S expression, "where the skin recedes more than in others;" and here he considers "this treatment becomes most necessary." (p. 210.) But to this it may be added, that they are very frequently employed to drag together the skin edges of a wound which, without them, could not be brought together at all. Or they are used without any reason whatever, as in scalp-wounds; of which HUNTER remarks, that "as the scalp probably recedes as little as any part of the body, it is therefore seldom necessary to apply any thing in wounds of that part.” (p. 210.) Or they are left in so long, even when their introduction has been proper, that they become irritants, and undo the good they might have served to. I cannot agree even with HUNTER upon the necessity of employing sutures, when parts recede from each other; nor with the practice of dragging them together with sutures when otherwise they cannot be retained in connexion, for this simple reason, that if they pull at all upon the parts they are purposed to unite, ulceration is immediately set up at the points where they press, and speedily they cut their way through and are entirely useless. In wounds of the scalp, or of other parts, which with a little management and by position may be kept together, they are unneeded, and, in the scalp especially, they often act as extraneous bodies and excite, or at any rate keep up, irritation, as is proved by the irritation subsiding when they are removed. They are also objectionable, under any circumstances, if left in after they have induced ulceration, which is a proof that the constitution is desirous of ridding itself of them; under this condition, independent of the irritation which they may, and often do produce, their occupation is gone; they become loose, and therefore no longer hold the parts together.

If judiciously employed, however, and not permitted to remain too long, sutures are often very useful. But their sole object is to keep parts which readily fall together or can be brought into contact, more steadily in their place, and to prevent them slipping one way or other out of their proper position, neither of which can be so well effected either by bandage or sticking plaster. Upon these principles alone should sutures be used, and not with the intention of forcibly bringing together parts which, from various causes, may be indisposed or incapable of themselves to come into contact. Thus it is very proper to connect by suture the edges of a wound of the eyelid, of the mouth, or even of the nose, either of which readily fall together; but unless retained in their place unite awry, and cause much disfigurement. But it is very improper, as well as very useless, to employ sutures in a wound across a muscle, which may or may not be involved in the wound; because the action of the muscular fibres will be constantly pulling the edges of the wound asunder, and thus dragging on the sutures, compel them to become irritants and excite ulceration, until they cut through and free the skin which they vainly attempt to confine.

As regards the time they should be allowed to remain, and during which they are of any real use, under the most favourable circumstances for their employment, as a general rule, from thirty to fifty hours is the utmost space of time for which they should be left. They should, if possible, always be removed either before or immediately after they have began to ulcerate, which is known by the needle-hole assuming a little redness and becoming moist by the welling up of a very minute quantity of pus, often, indeed, only sufficient to damp and thicken the thread. Directly this occurs, however soon it is observed, the suture should be cut on one side of its tie and removed, because from that time the suture has effected all it can do and begins to act as an irritant.

The number of sutures to be used depends on the nicety requisite to adjust the position of the divided parts; and they should never be thick, as the larger they are the more distinct will be the little hollow scars which they always leave. They should never be drawn so tightly as to pucker the edges of the skin which they include, but merely so tight as to bring the edges all but close; consequently the loop should be, when first

made, rather loose, as it soon becomes sufficiently tight by the outpouring of adhesive matter between the edges of the wound and into the neighbouring cellular tissue.

As a general rule I think it best, when sutures are put in, to make use of so many as without further assistance will keep the parts well in place, and then overlay the whole wound with a piece of soft linen dipped in cold water, which should be continually changed as it begins to dry; neither lint nor anything else which has upon it any fluff should be used for this purpose, as it entangles with the effused adhesive matter and at every removal disturbs the wound. The object of the cold application is to regulate the vascular action of the necessary inflammation. I rather prefer many sutures to the employment of few, which require the conjoint application of sticking plaster.

Sutures should only be employed when the wound is clean cut, never when it is much torn or bruised; as under the latter conditions union by adhesion cannot reasonably be expected to take place. A clean cut wound, made either accidentally, or purposely in operation, even though of several inches in length, will frequently be united throughout, if its edges be properly adjusted, in twenty or thirty hours. This observation especially applies to wounds of the face.

Wherever they can be used, and there is scarcely a case in which they cannot be employed, I prefer DIEFFENBACH's practice of using thin insect pins and the twisted suture; but all that has been stated in reference to the suture with thread, equally applies to that made with pins.-J. F. S.]

314. The sutures in use are, the Interrupted Suture, (Sutura nodosa, interscissa, Lat.; Knopfnaht, Germ.; Suture entrecoupée, Fr.,) the Twisted Suture, (Sutura convoluta, Lat.; Umwundene Naht, Germ. ; Suture entortillée, Fr.,) the Quill Suture, (Suture clavula, Lat.; Zapfennaht, Germ.; Suture enchevillée, Fr.,) and the Glover's Suture (Gastroraphe, Lat.; Darmnaht, Germ.; Suture des pelliers, Fr.) The interrupted and quill stitch will be here alone considered as those used in common wounds; the others will be, by-and-by, more particularly noticed.

315. For the application of the interrupted suture, a needle of good steel is to be used, curved, so as to form the segment of a circle, very pointed, and cutting on either side for a third of its length; the other end should be thinner, rounded off, and furnished with an eye; it is to be so held, in the right hand, that the thumb rests on the concave, and the fore and middle fingers on the convex side. At a distance from the edge of the wound, of from three to eight lines, (according to the gaping of the wound,) the needle is to be introduced, and, when the point has reached the bottom, a movement must be made, so that the opposite edge of the wound may be transfixed; to facilitate the passage of the needle the skin must be pressed against its point, with the thumb and fore finger of the left hand. When the needle has been drawn through, the waxed thread contained in its eye must be drawn after it, the edges of the wound brought into contact, and the ends of the thread tied so that the knot may be placed on one or other edge of the wound, and it is, also, to be particularly observed that the ends of the threads be not drawn together tighter than is necessary to bring the edges of the wound in close connexion. If the wound be very deep and gaping, the thread may be provided with two needles, and the edges of the wound pierced from within outwards. It depends on the size and direction of the wound how many stitches should be used; commonly a stitch to an inch is computed, but frequently one stitch is sufficient for a large wound, because the union of the rest of the wound is possible by means of sticking plaster. The first stitch should be in the middle of the wound, or at that spot where the edges of the wound, by reason of its form, most closely correspond (1).

Upon the different form of needles for wounds, see KROMBHOLZ'S Akologie, vol. i. p. 375. The application of a suture with a single thread, with which loops are formed, which are then cut through, is improper on account of the irritation of the wound of the needle by the drawing through of a long thread.

[(1.) So our old friend Maister GALE, who also gives the reason for his recommendation:"Make your first stiche in the middes of the wounde, than a finger breadeth from that make another on bothe sides of the midle stich, so leauing the space of a fynger breadeth, make so manye stiches as the wounde requireth. And take this for a generall rule that you neuer begynne your stiching at the ende of the wounde, because through that occation the wounde might be drawen awrye, and the member lose his beautie, and some tyme parte of his office. And beginning your stiches in the middes, this foloweth of necessitie that your stiches shal be odde, if there be more or lesse than twaine. And if the wounde be deepe and ouerthwarte the member, then you must make 'your stiches deeper, and that for two causes, the one for that it shoulde not breake out againe, the other that the wounde myghte haue lesse matter and better take consolidation. (pp. 2, 3.)]

316. The quill suture, especially employed for the union of wounds of the walls of the belly, but which is now almost out of use, is distinguished from the interrupted-stitch, inasmuch as the ligature consists of two threads separated on either side of the wound; between which threads small cylinders of wood corresponding with the length of the wound are interposed, upon which the threads are tied, so that the edges of the wound are compressed together throughout their whole length.

317. When the suture is applied, the union is to be assisted by sticking plaster, which is to be placed between the stitches; the wound is to be covered with fine charpie, with a compress, and the whole supported with some turns of a circular bandage.

318. The patient is to be kept at rest after the closing of the wound, and an antiphlogistic regimen pursued. If there be much traumatic reaction, active antiphlogistic remedies must be used. If severe pain and swelling of the edges of the wound occur, the bandage must be loosened, lead wash applied, and if, after the application of the sutures, the threads seem likely to tear through they must be removed, and the edges of the wound kept together with sticking plaster. If the loosening of the dressing, from these circumstances, or from after-bleeding, be not necessary, it may be left as long as it is not rendered too foul by the secretion from the wound. This at the first soaks into the dressings, subsequently dries, and the first dressing may, even in severe wounds, as in amputations, be often left until the cure is completed (in the strictest sense, per primam intentionem.) If the bandage be rendered too moist by the secretion from the wound, or if it have a bad smell, especially in hot weather, the superficial dressings must then be removed, but the sticking plaster left, if it keep the wound well closed. When, however, it is to be renewed, both ends of one piece of the sticking plaster must be loosened first towards the wound, and the middle part last, the edges of the wound being at the same time gently supported. As one piece of the plaster is removed, and the wound cleansed, another piece should be applied, because, if the wound be at once stripped of all the sticking plaster, the already united edges easily separate from each other. In this way the bandage is to be renewed daily, every other day less frequently, according to the quantity of secretion from the wound; in doing which it is also to be specially observed, that the connecting bandages are to be loosened with warm water previous to their removal, and the ligature threads not dragged. If stitches be used, the threads may be removed between the second and fifth days, the knot being cut, and the thread drawn through with forceps on the other side.

319. If quick union do not take place, or if, on account of its condition, (par. 308,) a wound cannot be brought together, it must heal by suppu

« PreviousContinue »