be deceived in some instances by clinical manifestations. Probably the best thing to be done where the tumor has already made its way from the antrum through the bony cavity into the mouth or on the side of the face, is to expose the alveolar ridge if the teeth have been removed, or if not, remove them and push back the soft tissue and make an opening in the antrum at that point, breaking away the most pendant portion of the superior maxillary until the cavity of the antrum has been fully exposed. The opening should be made large, sufficiently so to introduce the index finger, and in this way free drain

age is afforded and free access is obtained to the cavity, so as to enable us to do what is necessary to be done in the way of surgical interference. This is a much better operation than the entire removal of the superior maxillary, and much less formidable in every particular, and the same if not better results are obtained. If by chance the growth does not prove malignant the mouth is not spoiled, and, on the other hand, if it is malignant you have afforded the patient all the relief that it is possible to obtain, and as much as if the superior maxillary had been removed.

CASE 4. Master G., aged thirteen years, was brought to me April 20, 1901, for the purpose of having a tumor removed from the right upper eyelid. As is shown in Figure 1, the tumor is an inch and a

half long, one inch wide, and fully half an inch thick.

It occupied the space beneath the skin, covering the lid and mucous membrane lining that organ. Figure 2 represents the tumor in position before the operation.

The history of the case is that eight months ago, while at play, he received a lick on the eyelid from a companion. The lid became swollen as a result of the injury, but subsided with the exception of a slight enlargement, which never disappeared, but in a short time after the reception of the injury began to grow and developed into a tumor of enormous proportions, considering its position, in the very short space of less than eight months. The tumor was not painful, giving the boy no inconvenience aside from the sensation of weight attached to the lid and blindness produced from its position. The wounds were closed with silk sutures, the mucous surfaces being brought together first, and then the cutaneous surfaces were brought together in such a way as to have no dead spaces left. A compress was placed over the eye and allowed to remain forty-eight hours, at the end of which time the dressing was removed and the wound found to be perfectly clean. The stitches were subsequently removed, and the boy returned home and has had no further trouble.

The tumor was microscopically examined by Prof. John R. Wathen, and found to be small round-cell sarcoma.

LOUISVILLE.

THE STERILIZATION OF SUTURE MATERIAL.*

BY AUGUST SCHACHNER, M. D.

Professor of Surgery, Louisville Medical College.

The chances for the infection of a wound are greater from those bodies that are kept in contact with the wound for some time than from objects that are kept in contact but momentarily or for a short space of time. While it is important that all objects to which a wound is exposed should be at least practically sterile, it is highly imperative that those objects that are implanted in the wound for hours or days should be absolutely sterile.

For this reason our packings and suture and ligature material should command our utmost vigilance. Of the suture material we

* A paper read before the Kentucky State Medical Society, Louisville, May, 1901.

employ, the catgut gives us the most concern. The sterilization of catgut, especially the heavier varieties, is so difficult that for a time many believed that its absolute sterility was impossible. For this reason many operators, particularly on the other side of the Atlantic, have discarded and still discard catgut entirely. Silk has been substituted for the catgut because of its easier sterilization. The history of silk up to the time of its sterilization is a far cleaner one than that of catgut. In fact, if we consider the preparation of crude catgut, it is very remarkable that investigations should have demonstrated that the raw catgut is only occasionally infected with pyogenic organisms. For this reason, as several writers have suggested, most of the catgut has given satisfaction, even though its preparation for final use was of the most questionable nature. The bacteriological tests, and after all these are the only true tests, have not harmonized with the clinical results. The explanation for this discord is not a difficult one. We know full well that in every wound a certain number of organisms find entrance, and that the creation of a wound absolutely free of germs is an impossibility. With a more perfect knowledge of the infection of wounds and the conditions underlying the infection, we have learned to recognize that a wound containing germs is not an infected wound unless the germs which have found entrance into the wound have gained the supremacy in the struggle that always ensues in every wound between the entering germs and the opposing cells. For this reason catgut of a questionable nature from a bacteriological standpoint may be implanted into a wound without necessarily creating any disturbance. The opposing cells have been sufficient to destroy the organisms contained in the catgut, and all goes well. Should, however, the resistance offered the organism, either by reason of a general impaired vitality or because of some local condition, be insufficient to overcome the invading organisms, trouble will at once ensue.

We should not be satisfied with suture material that gives reasonable clinical satisfaction, but should endeavor to secure the material that will stand the most critical bacteriological tests. It would be somewhat surprising to one who had not investigated the subject to note the numerous methods that have from time to time been devised for the sterilization of catgut—a feature in itself quite sufficient to arouse a feeling of distrust in any of the methods. Dr. G. Brown Miller (Johns Hopkins Hospital Bul., Vol. XI, page 114), of the Johns Hopkins Hospital, has carefully studied from almost every standpoint.

the more promising methods, namely, Schaffer's, Vollmer's (Formalin), Reverdin's (Dry Heat), Krönig's (Cumol), Sweetnam's, and from which the writer has freely borrowed.

This inquiry has satisfied this operator (Dr. Miller) of the superiority of the cumol method over the others. Catgut prepared by this method is superior, not alone from a bacteriological standpoint, but is stronger and more pliable.

In the cumol method, as modified by Drs. J. G. Clark and G. Brown Miller, the gut is cut into lengths of 35 to 40 cm. or rolled upon spools. It is then heated at a temperature of 85° C. for about two hours to drive out all moisture. According to Saul (Archiv. f. Klin. Chir., Vol. 250, page 100), the average catgut contains 23 per cent moisture and 7.5 fatty matter.

The integrity of the catgut is largely dependent upon the thoroughness of its desiccation. If the catgut is not thoroughly dried before its exposure to a high temperature, it becomes brittle and useless.

After drying the catgut is transferred to the vessel containing the cumol and exposed to a temperature of 160-165° C. for one hour over a sand bath. It is removed from the cumol or the cumol is decanted, and the excess of cumol remaining in the catgut allowed to evaporate by leaving the vessel on the sand bath for one hour longer, the flame having been removed. The rolls of catgut are then placed in widemouthed sterile test-tubes, or the reels, if it is so arranged, transferred to their containers. Among the principal points which Dr. Miller mentions is to have an apparatus arranged in such a manner that the vapor of cumol does not come in contact with the flame or red-hot metal, since the vapor of cumol is heavier than air and is inflammable, but not explosive.

Such an apparatus has been designed by Dr. John G. Clark, of Philadelphia. Dr. Miller has still further elaborated upon this method by placing the catgut in solutions of formalin of varying strengths before sterilization, thus increasing the time required for its absorption.

The ligature reel herein described was designed to replace the glass boxes, which are generally considered the most aseptic arrangement at present at our disposal. This reel has not alone all the advantages that apply to the glass arrangement, but has some additional advantages, namely: being of metal, we are insured against its breakage, and for that reason never exposed to the danger of an accident to the ligature outfit. Not only this, but the durability of the metal

box is greater than that of a glass one. It is true that a glass box has a slight advantage over the metal one in looks, and for that reason the glass box may still receive the preference when it comes to hospitals.

It is in portability that the metal ligature outfit comes in for its full measure of advantage over its rival, the glass outfit. It is when we are obliged to operate away from hospitals, either in the city or especially in the country, and where we can not always judge the amount and character of suture material that might be called for, that we feel the need of an outfit that is practical in every sense, namely, portability, without danger of breakage, and liberal supply of all possible material. Another need that this reel will supply is in military surgery, where a large amount of material can be safely carried.

Description of Reel. The reel can be constructed in different sizes; the most convenient for ordinary purposes is the one herein described. A cylindrical box 31⁄2 inches in circumference and 3%1⁄2 inches space in length. The box is supplied with a double cover to insure the greatest protection to its contents. The first, an outside cover, overlaps the case. The second, an inside cover, screws itself into security by means of threads cut into a strip that is soldered in the inside of the case about 3/4 of an inch from the top. The edge of the inside cover is supplied with a narrow flange. When this cover is screwed into position this flange rests upon the strip, thereby doubly sealing the interior. The space between the covers measures 1⁄2 inch. From the bottom of the case arises a stationary upright rod. This rod is flared out at the top so as to present a circular surface about 3/4 of an inch in diameter. From the center of this surface arises a short screw, and radiating in a crucial manner from the base of this screw are found square excavations to receive the ends of the frames that hold the spools. These frames are held in position (a) by accurately fitting into the square excavations; (b) by being supplied with a small peg which fits into an aperture near the edge of the square excavation; (c) by being held in this square excavation by the impingement from above. This screw arising from the center of the disk surmounting the upright pole receives its mate, a form of thumbscrew, the bottom of which is flared out to correspond to the flared out top of the central pole. From this it is apparent that the purchase gained by this arrangement is similar to vise in its method, but far more effective in its mechanism. The frames that hold the reels are thus firmly held in position without the possibility of any wabble in any direction.