■■■■■■■■ 2023■■ 9th Edition

■■■■■
Visit to download the full and correct content document:
https://ebookstep.com/download/ebook-55776650/
More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Aula Internacional Plus 4 B2 1 1st Edition Difusión

https://ebookstep.com/product/aula-internacional-plus-4-b2-1-1st-
edition-difusion/

Edito B2 4e édition 4th Edition Myriam Abou-Samra

https://ebookstep.com/product/edito-b2-4e-edition-4th-edition-
myriam-abou-samra/

Gesamtausgabe Bd 91 Ergänzungen und Denksplitter IV

ABTEILUNG HINWEISE UND AUFZEICHNUNGEN Martin Heidegger
Mark Michalski Editor

https://ebookstep.com/product/gesamtausgabe-bd-91-erganzungen-
und-denksplitter-iv-abteilung-hinweise-und-aufzeichnungen-martin-
heidegger-mark-michalski-editor/

L eredità B1 B2 Primi Racconti 1st Edition Luisa Brisi

https://ebookstep.com/product/l-eredita-b1-b2-primi-racconti-1st-
edition-luisa-brisi/
1000 Questions 1000 Answers angol középfok B2 Némethné
Hock Ildikó

https://ebookstep.com/product/1000-questions-1000-answers-angol-
kozepfok-b2-nemethne-hock-ildiko/

Nagy Origó nyelvvizsgakönyv Angol középfok B2 Horváth

Miklós Zsigmond Ildikó

https://ebookstep.com/product/nagy-origo-nyelvvizsgakonyv-angol-
kozepfok-b2-horvath-miklos-zsigmond-ildiko/

■■■■■■■■■■ ■■■■ ■■■ ■■■■■■■■■■■ B1 B2 3rd Edition ■

■■■■■■■■■

https://ebookstep.com/download/ebook-29840068/

Ritorno alle origini B1 B2 Primi Racconti 1st Edition

Valentina Mapelli

https://ebookstep.com/product/ritorno-alle-origini-b1-b2-primi-
racconti-1st-edition-valentina-mapelli/

Let s Discuss It B2 1st Edition Kész Zoltán Stanley A

Ward

https://ebookstep.com/product/let-s-discuss-it-b2-1st-edition-
kesz-zoltan-stanley-a-ward/
Another random document with
no related content on Scribd:
Fig. 17.—Dressing Case.
 Fig. 18.—Combination Dressing Case and Table.

Waste Cans.—All soiled dressings and sponges should be

immediately thrown into an enameled iron pail furnished for the
purpose. At no time must soiled dressings or sponges be thrown
upon the floor, where they are walked over, soiling the floor and, by
drying, contaminating the air of the room. Cans for this purpose are
made of steel, enameled, of the form shown in Fig. 19.
The contents of the can must be taken from the room after each
operation and burned. The can should be flushed with carbolic
solution, and returned to the operating room.
 Fig. 19.—Waste Can.

SUTURES AND STERILIZATION

(Ligatures)
Silkworm Gut and Silk.—In plastic surgery silkworm gut and silk
are used extensively. Rarely is ordinary catgut resorted to, because
it is absorbed before thorough union takes place, besides being a
source of infection, either primarily from imperfect sterilization or by
taking it up from the secretions of the deeper layer of skin not
affected by external antiseptics.
The sterilization of silk is accomplished by boiling it for one hour in
a 1-20 carbolic solution and then keeping it in a 1-50 similar solution
(Czerny). Or it may be boiled in water for one hour and retained in a
1-1,000 alcoholic solution of corrosive sublimate. Ordinarily it may,
however, be simply subjected to boiling and steamed in the
autocleve. Silkworm gut is treated in the same manner. It has greater
tensile strength than silk, and for that reason the thinner varieties are
to be preferred to ordinary silk.
Catgut.—It is far more difficult to prepare catgut, but, since it is
necessary for ligation, the following methods may be considered
best:
The commercial catgut as made from the intestines of sheep, is
wound snugly upon a rod of glass and thoroughly brushed with soft
soap and hot water. It is then rinsed free of soap, wound upon small
glass spools, and placed for forty-eight hours in a one-per-cent
alcoholic bichlorid solution, composed of bichlorid of mercury, 10
parts; alcohol, 800 parts; distilled water, 200 parts. The turbid fluid
produced by first immersion is changed. Before using, the spools are
placed in a glass vessel contain containing a 1-2,000 sublimate
alcohol (Schaffer), made up as follows:

Bichlorid of mercury gr. vj;

Alcohol ℥x;
Distilled water ℥iiss.

These glass cases are obtainable for the purpose and contain a
second perforated compartment for the ligatures passing through
rubber valves placed into the openings (Haagedorn).
Catgut is generally prepared by soaking in oil of juniper for one
week and then retaining it in absolute alcohol (Kocher), or a 1-1,000
alcoholic sublimate solution.
Another method for strengthening catgut, as well as to prevent its
too rapid absorption, is to chromatize it. This is done as follows:
The catgut is placed in sulphuric ether for forty-eight hours, then
treated for another forty-eight hours in a ten-per-cent solution of
carbolized glycerin, followed by a five-hour subjection to a five-per-
cent aqueous solution of chromic acid (Lister). It is allowed to remain
in the latter forty-eight hours, then placed in an antiseptic, dry, tightly
closed receptacle, and finally soaked in 1-20 carbolic solution before
using.
 The formaldehyd method of Kossman is to immerse the gut in
formaldehyd for twenty-four hours, then washing with a solution of
chlorid and carbonate of sodium and retaining it in the same solution.
The catgut in this procedure swells and its strength is much impaired
in this way.
Any of the above methods are not above criticism, however, rigid
as they may seem, bacterial growths having been obtained with
nearly all of them.
The dry-air method (Boeckman, Reverdin) is reliable, but the
subjection of catgut to dry air at a temperature of 303° F. for two
hours results in making it tender and less pliable.

Fig. 20.—Clark Kumol Apparatus.

 The Kumol method (Kronig) is considered the most reliable, even
under the severest tests. This mode of sterilization is accomplished
as follows: A specially devised apparatus of brass, with a cast-
bronze top, both thoroughly nickel-plated, is used. The apparatus of
J. G. Clark, as shown in Fig. 20, will be found excellent. The kumol is
retained in a seamless cylinder, 8 by 8 inches, which is surrounded
on the sides and bottom by a sand bath; the flame, impinging on the
bottom, heats the sand, thereby insuring an even heat to the inner or
sterilizing cylinder. The catgut, in rings, is placed in a perforated
basket hanging in the cylinder, which can be raised or lowered at
will; after drying for two hours at 80° C., the basket is dropped, and
the catgut immersed in the kumol, at 155° C., for one hour; the
kumol is then drawn off through a long rubber tube, and the catgut
dried at 100° C., for two hours; it is then transferred to sterile glass
tubes plugged with cotton.
Prepared catgut of the various sizes can now, however, be
purchased in the market, and that offered by the better firms of
chemists is quite reliable and may be safely used for all plastic
surgery about the face. It is supplied in glass tubes, either in given
lengths, as in the Fowler type, in which the hermetically sealed tube
is U-shaped or on glass spools placed in glass tubes, not sealed, but
closed by a rubber cap, through which the desired length of ligature
is drawn and then cut off.
 CHAPTER IV
PREFERRED ANTISEPTICS

ANTISEPTIC SOLUTIONS
These are solutions used for the destruction of and to arrest the
progress of microörganisms that have found their way into wounds—
the cause of sepsis, as exhibited by fever, suppuration, and
putrefaction. These preparations are called antiseptics and are used
to render parts aseptic. They vary much in their destructive power,
effect on tissue, and toxic properties. The reader is referred to a
work on bacteriology for the specific knowledge of such on germ life.
The antiseptic treatment of wounds was founded by Joseph Lister,
1865-70, then called Listerism. His one chemical agent to
accomplish this was carbolic acid, but many such and more effective
agents have been added since that time, all differing in their specific
properties and each having, for the same reason, its particular use.
The following group of antiseptics has been chosen with a view of
giving the best selection, to which the author has added a short
description of each, so that the surgeon may choose one or the
other, as the occasion may demand. As a rule, an operator cultivates
the use of a certain line of antisepsis, especially in this branch of
surgery, experience being the best guide; yet it is hoped he may find
certain aid from those referred to, their particular use being pointed
out from time to time, as the author has had occasion to prefer one
or the other.
Alcohol (absolute).—This is a well-known antiseptic, but, because
of its ready evaporation, is especially used for the hands, as
described, and to cover sharp-edged instruments after sterilization.
Aluminum Acetate (Bürow, H. Maas).—A powerful, nontoxic
antiseptic. Is used only in two- to five-per-cent solution. According to
Primer, it arrests the development of schizomycetes, and in twenty-
four hours destroys their propagation. It readily removes offensive
odors of wounds; its great objections are that it injures the
instruments, and, because of its astringent nature, roughens the skin
of the hands. This, however, makes it particularly useful for sponging
to arrest capillary oozing.
Boric Acid (Lister).—Not a powerful, but nonirritating, antiseptic.
For this reason it is used extensively in cleansing mucous
membranes, and, when associated with salicylic acid, as in the well-
known Thiersch solutions, composed of salicylic acid, 2 gms.; boric
acid, 12 gms.; water, 1,000 gms., is much used in skin-grafting
operations. It is not very soluble in cold, but readily in hot, water and
alcohol. The saturated solution is prepared by adding ℥j to the pint of
boiling water.
Benzoic Acid.—Nonirritating, moderate antiseptic (Kraske); is
prepared in 1-250 solutions. Soluble in hot water and alcohol, but
sparingly in cold water.
Carbolic Acid (Phenylic Acid).—Not a powerful, but a much-used
antiseptic. The purest acid should be used. It appears as a colorless
crystalline solid, liquefied by the addition of five per cent water. If
more water is added the solution becomes turbid, clearing when 1-
2,000 is reached.
It is readily soluble in glycerin, alcohol, ether, and the fixed volatile
oils. Solutions in alcohol and oils have no antiseptic effect (Koch).
The 1-20 aqueous solution is recommended by Lister.
The aqueous solutions used in surgery are 1-20 and 1-40. The
weaker is used for the operator’s hands, to cover instruments, as
already mentioned, and to impregnate sponges. The stronger
solution is used for the carbolic spray, to cleanse the unbroken skin
about the site of operation, and to disinfect wounds. Either solution,
when applied to an open wound, whitens the raw surface,
coagulates the albumen, and causes considerable irritation, which
subsides quickly and is followed by numbness.
 Such solutions, by virtue of their irritant nature, increase the
serous discharge from a wound for about twenty-four hours, for
which proper drainage must be provided, as by its collection it would
add to the danger by increasing inflammation and suppuration, and,
by absorption, even produce toxic effect generally.
When a cold solution is used it should be prepared by vigorous
stirring to separate the globules of the acid. Hot water insures perfect
distribution. After an infected wound is washed with it, the solution
should not again be used, nor should any of the acid be permitted to
remain in the spaces about the wound. It will be found that many
patients cannot tolerate such dressings, and that others must be
substituted.
Large surfaces should never be exposed to carbolic solutions,
because the skin absorbs them readily, followed by untoward results.
Dangerous symptoms have been known to result from the internal
administration of seven drops of the acid, and fatal termination has
followed its use as a surgical dressing (Bartley).
Mild acid poisoning is first noted in the urine, which turns olive
green. If the agent is continued, the urine appears dark and turns
almost black on standing. The coloring is due to the presence of
indican. If the absorption is not prevented beyond this there is dull
frontal aching, tinnitus aurium, dizziness, fainting, severe and
uncontrollable vomiting. Untoward symptoms are noted by
albuminuria, total absence of sulphates in the urine, a contracted
and inactive pupil, elevation of temperature, unconsciousness,
muscular contraction, and death.
The treatment consists in immediately removing the cause and
employing another antiseptic. Support the patient with stimulants,
freely given. Cracked ice and brandy to allay the vomiting. Small
doses of sodium sulphate, frequently repeated, as a means of
converting the acid into nonpoisonous sulphocarbolate (Bauman).
Albumen and milk internally. Magnesium sulphate, five per cent.
Chromic Anhydrid.—Improperly called chromic acid. Made by
adding one and one half parts sulphuric acid, c. p., to one part of
concentrated solution of dichromate of potash. Appears in saffron-
colored crystals. It acts as a caustic upon tissue, and, although a
splendid antiseptic, cannot be used for such purposes, but is well
adapted for the preparation of catgut, as mentioned.
Creolin.—Is an antiseptic prepared from coal by dry distillation,
and is used to stimulate granulations, being much more powerful
than carbolic acid. It is nonirritant and practically nontoxic. Used in
two-per-cent aqueous solutions, in which it appears as a turbid but
effective mixture. It is well suited for cleansing the hands, a five-per-
cent solution having none of the irritating or anesthetic effect of
carbolic acid. Owing to the opacity of the aqueous solution, it is not
suitable for the immersion of instruments for operation.
Eucalyptol (W. Schultz).—A nonpoisonous volatile oil of
considerable antiseptic power. Soluble in alcohol, and used in three-
per-cent solution. It is claimed to quickly reduce the temperature in a
wound. It was much used by Lister on gauze dressings, the formula
of which is given elsewhere.
Glycerin.—It is said to have certain antiseptic power, but is used
principally as a staple solvent of carbolic and boric acid. Soluble in
all proportions in water and alcohol.
Hydrargyrum Bichloratum Corrosivum (v. Bergman, Schede,
Buchholz, Billroth, R. Koch).—The most valuable and effective,
although the most toxic of all antiseptics. It appears as a white
crystalline powder. A 1-50,000 watery solution is efficacious as a
germicide (Koch; anthrax bacilli killed by 1-20,000 solution).
Albumen decomposes the bichlorid, forming a white insoluble
precipitate, albuminate of mercury. The same effect takes place in
aqueous solutions allowed to stand for a time—the resultant being
either calomel or metallic mercury. The addition of sodium or
ammonium chlorid or a weak acid, such as tartaric, prevents this. As
much sodium as of the sublimate, weight for weight, should be used
(Koch). When tartaric acid is used for this purpose, five times the
weight of the sublimate is employed.
For all surgical purposes, except in irrigation, solutions of 1-500
and 1-1,000 are used. For the sterilization of wounds and during
operations a 1-3,000 is employed.
 For the ready preparation of such solutions sublimate tablets can
be obtained, properly mixed with one of the above-named salts. The
dyed tablets are to be preferred, to prevent error on the part of the
user. Tablets containing 1 gm. sublimate, 1 gm. sodium chlorid, and
colored with eosin, are advocated by Angerer.
As metallic substances immediately decompose the bichlorid in
solution, instruments cannot be placed in it, nor may it be kept in
metallic vessels, glass being preferred.
Alcoholic solutions of sublimate are used to cover catgut, silk, and
rubber drainage tubes.
Since sublimate is extremely toxic, great care must be used to
prevent its absorption or retention in wounds. A strong solution must
immediately be followed by a weaker one.
Toxic symptoms resemble arsenic poisoning very much, and are
ushered in by an acute irritation of the wound, especially if moist
sublimated gauze has been used, vertigo, and vomiting. The mucous
membrane of the mouth becomes affected, followed by salivation
and bleeding from the gums. There may be intestinal hemorrhage
and an inflammation of the entire intestinal tract and kidneys,
increasing in severity and resulting in death.
The early symptoms must be at once met by removal of the cause.
Albumen and milk should be given internally, with stimulants as
needed. The mouth is to be rinsed out at frequent intervals with a
saturated solution of chlorate of potash.
Hydrogen Peroxid (Love).—A powerful nontoxic antiseptic. It is
used in five- to fifty-per-cent aqueous solutions, and is most
efficacious in suppurating wounds, in which it destroys the
microörganisms of pus. It foams actively when brought in contact
with the latter, and is said to render a wound aseptic by one or two
applications. A standard preparation of known strength must be
obtained, however, to get good results.
Iodin.—A very powerful nonirritating antiseptic. Used especially
for washing wounds. The proper solution is made by mixing two
drams of the tincture (℥j iodin to ℥Oj alcohol) with one pint of warm
water (Bryant). The one-per-cent solution of the trichlorid is equal in
its effectiveness to a four-per-cent carbolic solution (Langenbuch).
Lysol.—Very similar to creolin, both in composition and effect. Is
nontoxic, and employed in two-per-cent aqueous solution. Appears
as a soapy liquid, and forms a clear solution with water.
Potassium Permanganate.—An active disinfectant, quickly
destroying the odor of decomposition, and for that reason is splendid
for the washing out of foul wounds. It is nonpoisonous, and has
moderate antiseptic power—the five-per-cent solution killing resting
spores. Its effect is limited to a short time only, as the secretions from
a wound decompose and precipitate it into an inactive form. It is
employed in aqueous solution, differing in color from light ruby to
dark brown; that is, 1-1,000 to 1-100. The solution, known as
Condy’s Fluid, has a strength of 1-1,000.
Salicylic Acid.—A derivative of carbolic acid, and an effective
nonirritating antiseptic. It is only slightly soluble in cold water, 1-300.
When combined with boric acid, it becomes more soluble. This
antiseptic cannot be used for instruments, however, as it corrodes
them. Its other objections are that it evaporates quickly from
dressings and that it is expensive.
Sodium Chlorid.—Is a common agent used for the irrigation of
putrid wounds in two-per-cent solution. For irrigation during aseptic
operation and for covering sterilized sponges it is used in eight-per-
cent solution (v. Esmarch). This corresponding to the normal salt
solution. Its use in connection with corrosive-sublimate solutions
(Maas) has been referred to.
Thymol (Rancke, Bouillon, Paquel).—The aromatic principle of
thyme. Efficient as an antiseptic in 1-1,000 aqueous solution. It has a
pleasant odor, and is nonirritant and nontoxic. Exhibited in colorless
crystals. An excellent solution is prepared as follows:

℞ Thymol 20 parts
Alcohol 10 ”
Glycerin 20 ”
 Aquæ 1,000 ”

It is used especially in washing out cavities where carbolic acid

cannot be employed, and for cleansing mucous membranes
preparatory to operation.
Zinc Chlorid (Morgan, Bardeleben, Billroth).—Extensively used
as an antiseptic, especially in the oral cavity, where, by sealing the
lymph spaces with a plastic exudate, it hinders the absorption of
septic matter. It is only slightly antiseptic, however, in ten-per-cent
aqueous solution. Zinc chlorid represents the active agent in
Burnett’s fluid. May be effectively employed in the proportions of
from twenty to forty grains to the ounce of water. Care must be
exercised to prevent its retention in alveolar tissue, since it may
occasion serious sloughing. As a cleansing agent for infected
wounds it is of great value, although the sulphocarbolate of zinc may
be preferred, as it is less irritating and less toxic.
Peroxoles.—Beck has introduced a group of preparations, known
as peroxoles; liquid antiseptics containing a solution of hydrogen
peroxid in combination with other disinfectants. The preparations are
composed of from thirty-three to thirty-eight per cent alcohol, about
three per cent of hydrogen peroxid, and one per cent of thymol,
menthol, or camphor, the name given them being according to the
last ingredient—thymosol, menthosol, or camphorosol. The
association with these disinfectants greatly increases the antiseptic
power of hydrogen peroxid. Aqueous solutions containing ten per
cent of the peroxoles are usually employed. These correspond to a
one-per-cent solution of mercuric chlorid, and possess a more
energetic action than five per cent carbolic acid.

ANTISEPTIC POWDERS
Aristol (Dithymol Di-iodid) (Eichhoff).—Reddish-brown powder
containing forty per cent iodin. Soluble in ether, chloroform, and fatty
oils, sparingly in alcohol. Must be kept in dark glass bottles. Is
incompatible with corrosive solutions. Used externally as iodoform.
 Dermatol (Bismuth Subgallate).—An odorless yellow insoluble
powder, containing fifty-three per cent Bi₂O₃.
Iodol (Tetraido Pyrol) (Kalle).—A light grayish-brown powder,
containing eighty-nine per cent iodid. Slightly soluble in water,
soluble in alcohol and chloroform. Its action is very similar to
iodoform, and has taken its place to a great extent, first, because it is
odorless, and secondly, because any quantity used exerts no toxic
effect (Wolfenden). It is dusted upon the wound. Its action is due to
the liberation of iodin, which acts upon the albuminous elements,
and the ozone set free oxidizes the products of decomposition. It has
a slight escharotic effect, forming a thin crust over the surface to
which it is applied, thus effectually remaining in constant contact with
it. That it is quickly absorbed is shown by its presence in the saliva
and the urine.
Orthoform (Methyl Ester of Meta-Amido-Para-Oxybenzoic Acid).
—Nonpoisonous, white, odorless powder of moderate antiseptic
power, and well suited for wounds involving mucous membranes. It
has a decided anesthetic effect, lasting for several hours upon
painful wound surfaces.
Iodoform (Formyl Iodid, Féréol).—A lemon-yellow crystalline
powder of penetrating, saffronlike odor. Contains ninety-seven per
cent iodin. Insoluble in water, but forms solution with alcohol, ether,
chloroform, and the fixed volatile oils. Has a decided stimulating
effect on wounds by preventing putrefaction and deodorization
(Mikulicz). Its antiseptic value has been much discussed, but
practically it has found favor with the majority of surgeons. According
to research, iodoform is a powerful antiseptic, from the fact that the
product of its decomposition in the presence of germ life renders the
ptomains in a wound inert, thus preventing suppuration, or at least
checking the absorption of such, which is often a serious matter in
infected wounds. It is not sterile, and may contain ptomains which in
themselves would produce pus, but as associated with the iodoform
do not occasion it.
 CHAPTER V
WOUND DRESSINGS

The dressing or treatment of wounds, considered herein,

embodies particularly that practiced by the surgeon in the
performance of plastic operations.
The elasticity of the skin is especially serviceable in bringing about
desirable restorative results, but, owing to its extreme vascularity
and the infrequent supply of venous valves, as in the face, there is
considerable danger of infection, with rapidly spreading septic
inflammation.
Sutured Wounds.—Before the wound is closed all hemorrhage
must be arrested, either by catgut ligature, in exceptional cases, and
by torsion or pressure, as generally practiced. Gauze sponges
dipped into hot sterilized solution are most suitable for the latter
purpose.
The edges of the wound must be coapted perfectly by cutaneous
sutures of sterilized silk of suitable thickness. Formaldehyd catgut is
often used because of its limited absorption. Ordinary catgut should
not be employed, as its early absorption interferes with obtaining the
proper union, and by becoming softened invites sepsis.
The wound, if small, may be powdered over with any of the
antiseptic powders, such as aristol or iodol. It must be remembered
that such powders form a hard crust with the serous oozing of
wounds, which, by reason of pressure from the dressing applied over
it, is very liable to separate the edges of the wound, thus increasing
the width of the scar, a very important factor in facial surgery.
Where perfect apposition has been made, the dusting powders
may be used and a covering of Lister’s protective silk plaster placed
over it. The edge of the strips of plaster must be incised at distances
of about ⅛ inch, so as to snugly take on the curvature of the parts
and at the same time thoroughly seal over the area to prevent
subsequent contamination.
The plaster is made of taffeta silk, preferably of flesh color, coated
on one side with copal varnish and a mixture prepared as follows:

℞ Dextrin ʒj;
Starch ʒij;
Carbolic acid ℥ij.

When applied, it should be moistened with an antiseptic solution

only. This can be applied only to dry surfaces, however, and should
be rarely used, since subsequent hemorrhage or oozing will raise the
plasters, inviting sepsis.
It is better, however, in all cases to employ several layers of an
antiseptic gauze, such as fifteen-per-cent iodoform or boric-acid
gauze to cover the wound, and back it with absorbent cotton, over
which a bandage or the silk protective is applied to retain it. The
gauze absorbs the secretions, at the same time rendering them
harmless.
At no time should cotton be placed next to the wound, as it forms a
hard mass with the secretions, the removal of which requires enough
force to injure or hazard the union of a new wound. Nor should a
plaster dressing be pulled off without thoroughly moistening it first,
withdrawing the various layers one by one. The gauze, when
moistened, readily leaves the wound without injurious traction. An
excellent dressing for small, dry wounds, and one that causes little
tension, is collodium, or, better, iodoform-collodium painted over the
surface. The latter may be prepared as follows;

℞ Iodoformum 5j;
Collodium 5x.
[Küster.]

To this may be added oil of turpentine or castor oil, which permits of

greater flexibility. Boric lint, applied wet, is also good. It must be
moistened thoroughly before removal. Larger wounds should be
dusted over with one of the powders mentioned and covered with
folds of gauze and absorbent cotton, held in place with gauze
bandages.
Such dressings are allowed to remain until the sutures are taken
out, unless there is sign of soiling. As these secretions readily
decompose, it is best to remove the cotton and upper layers of
gauze and renew them every day, or as often as is necessary. The
wound, in this way, is not disturbed whatever, and the antiseptic
properties of the lower fold of gauze is sufficient to keep the wound
surface clean.
In most superficial wounds it is best to remove the sutures at the
end of forty-eight hours, unless there are reasons for retaining them
longer, as the coapted surfaces are then sufficiently united to permit
of other dressings, such as aseptic plaster, now extensively used.
Before these are applied the skin is washed with alcohol or ether to
assure a dry surface to facilitate adhesion.
Sutures drawn as stated leave no possibility of stitch scars and
reduce the occurrence of possible stitch abscess to a minimum. As
there is always slight oozing following their removal, aristol or iodol
may be powdered over them before applying the plasters. This
brings us to the rather late question of sutureless coaptation of
superficial incisions.
Sutureless Coaptation.—This method, first practically
demonstrated by Bretz, may be used with considerable advantage in
wounds about the face, and overcomes the strain of individual
sutures, besides avoiding the possibilities of stitch infection.
 Fig. 21. Fig. 22.
Plaster Sutures.

The method involves the proper placing of strips of plaster at

either or opposite ends of the wound. The distance between the
incision and the edge of the plaster must not be less than ¼ inch or
more, according to the length of the wound and its position. In place
of the strips of rubber adhesive plaster, the aseptic Z. O. plaster
should be substituted to overcome the objections of the infections
therefrom.
 Fig. 23. Fig. 24.
Angular Plaster Sutures.

The inner edges of the plasters are raised slightly, and interrupted
sutures are inserted through them instead of the skin (see Fig. 21).
They are then tied as shown in Fig. 22. In angular incisions the
plasters are cut as desired to insure perfect coaptation, as in Figs.
23 and 24. The advantages of this method, besides those already
mentioned, are that the wound is always open for inspection and
permits of free drainage. If thought best, a small strip of iodoform
gauze may be placed over the threads or even under them, if there
is little tension.
Since the introduction of the aseptic Z. O. (Lilienthal) strips, the
above method may be discarded as unnecessary and requiring too
much time for their application. Strips of the antiseptic plaster are
placed across the wound at right angles, or, if the surface be a
curved one, obliquely to the wound. The plasters are furnished in
strips of the width desired, packed in two germ-proof envelopes.
They are extremely adhesive to dry surfaces. Besides being aseptic,
they are slightly antiseptic and nonirritating. The strips are placed in
position, leaving an open space between them while the assistant
brings the edges of the wound into position.
Where there is tension of the parts this method is not to be
employed. The wound may be dusted as when sutured and dressed
in the same manner. The plasters are removed about the sixth day
by drawing the ends of the strips toward the wound. Their second
application is unnecessary, regular dressings being substituted.
From the above it must not be inferred that all plastic wounds are
amenable to the above methods, because many require specific
treatment, as later described.
Granulation.—Wounds left open for granulation should be dusted
over with some stimulating antiseptic powder, such as aristol or boric
acid, and then covered with iodoform or borated gauze. The
granulating surface must be gently washed with a mild solution of
peroxid.
Prolific hypertrophic granulations, that jut out over the surface, are
touched with a lunar caustic point, avoiding the epithelial edge of the
wound, where it causes considerable pain. Pale and loose granular
points should be scraped away with the sharp spoon curette to
hasten better growth.
If the skin edges are thickened and curled upon themselves, it
may be best to curette or to reduce them by cauterization, so
stimulating epitheliar spreading. Sterile gauze is then loosely laid
upon the surface, backed with a highly absorbing material, such at
charpie cotton (Burns), wood wool, and poplar sawdust, retained in
gauze bags (Porter). The absorbing layer should be light and
pervious to the air, to facilitate not only free absorption, but ready
evaporation of the secretions.
Changing Dressings.—All dressings must be absolutely sterile
and all precautions, as primarily carried out, must be followed in
changing them.
It is rather infrequent to use permanent dressings in plastic
surgery, but where the wound appears aseptic, with a dry serous
crust over the line of healing, it should not be disturbed except for