An American text-book of surgery : for practitioners and students / By Phineas S. Conner, M.D., Frederic S. Dennis, M.D., William W. Keen, M.D., Charles B. Nancrede, M.D., Roswell Park, M.D., Lewis S. Pilcher, M.D., Nicholas Senn, M.D., Francis J. Shepherd, M.D., Lewis A. Stimson, M.D., J. Collins Warren, M.D., and J. William White, M.D. Ed. by William W. Keen and J. William White.

  • William Williams Keen
Date:
1899
Catalogue details

Licence: Public Domain Mark

Credit: An American text-book of surgery : for practitioners and students / By Phineas S. Conner, M.D., Frederic S. Dennis, M.D., William W. Keen, M.D., Charles B. Nancrede, M.D., Roswell Park, M.D., Lewis S. Pilcher, M.D., Nicholas Senn, M.D., Francis J. Shepherd, M.D., Lewis A. Stimson, M.D., J. Collins Warren, M.D., and J. William White, M.D. Ed. by William W. Keen and J. William White. Source: Wellcome Collection.

Provider: This material has been provided by the Augustus C. Long Health Sciences Library at Columbia University and Columbia University Libraries/Information Services, through the Medical Heritage Library. The original may be consulted at the the Augustus C. Long Health Sciences Library at Columbia University and Columbia University.

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    ing cavities, resort must be had to taiii])oning the wound-cavities with materials impregnated with a permanent antiseptic, as iodoform or boric or salicylic acid. In these latter cases, of course, union by granulation is what commonly occui's, but what is practically primary union may sometimes be attained by secondary sutures. Coaptation.—In the coaptation of wounds the aim of the surgeon must be to bring the severed parts as far as possible into the same relations with each other as existed before the wound was inflicted, and especially to secure the closest possible apposition of eveiy portion of the wound-surfaces. When im})ortant nerves, muscles, and tendons have been divided, especial care must be taken to bring and secure together the divided ends; all dead spaces where secretions may gather are to be prevented; and by various means and devices the tissues are to be retained in their restored relation until definite reunion has been accomplished. Under the term coaptation all the various aims and methods referred to are included. In the section devoted to Minor Suro-erv the means of accomplishing coaptation ai'e described in detail. Here, however, it will be proper to speak of the general principles which should guide the surgeon in the choice of means and methods. First, much tension must be avoided. When tissues are put unduly upon the stretch in an effort to bring them together, the circulation of the blood within them is impeded, ' nutrition is impaired, the formation of sloughs is invited, and suppurative disturbances are promoted. It is far better to be content with whatever amount of coaptation can be easily secured, and to seek for the healing of any surfaces left uncovered, either by granulation and ulti- mate cicatrization or by skin-grafts. In the second place, care must be taken w^ile securing coaptation to avoid such adjustment of sutures or other retentive apparatus as would be likely to produce strangulation of any portion of the tissue. Sutures too closely applied and too tightly drawn are a frequent cause of necrosis of wound-edges: the pressure of compresses and bandages may likewise be so great as to produce local tissue-necrosis, so that good judg- meiat should always be used in their application. Thirdly, the relaxation of tissues by position should not be overlooked by the surgeon. The spontaneous gaping or falling together of wounds in varying attitudes of a wounded part need but be noticed to suggest the advantage to be derived from placing a part in that position or attitude in which any tendency to gape during the healing process will be reduced to a minimum. The general rule is, therefore, in order to favor coaptation of a wound, to put the part in that position in which the greatest relaxation of the wounded structures can be secured, and in this position they should be fixed and held until firm union has been accomplished. As an accessory to the use of position for securing relaxation is the device of sliding toward the wound tissues somewhat distant from it. By the use of sutures traversing a deeper portion of the wound, and made to embrace portions of tissue on either side at a considerable distance from the wound-edges, and then secured after the manner in which an upholsterer secures the two sides of a mattress together, wounds which gape widely at first may often have their edges so approximated that they are easily brought together without tension. The choice of materials for ensuring continued coaptation is worthy of con- sideration. When a wound is small and there is no tendency to gape, or when that tendency has been overcome by attention to position, the use of a simple compress held in place by a roller bandage may be all that is required to ensure undisturbed healing. In general, however, additional means for secur- ing undisturbed coaptation will be required. For this purpose are used adhe- sive strips and sutures.