Volume 1

The science and art of surgery : a treatise on surgical injuries, diseases, and operations / by John Eric Erichsen.

John Eric Erichsen

Date:: 1895

Credit: The science and art of surgery : a treatise on surgical injuries, diseases, and operations / by John Eric Erichsen. Source: Wellcome Collection.

Provider: This material has been provided by The University of Leeds Library. The original may be consulted at The University of Leeds Library.

105/1274 (page 73)

$Surgeon being guided by his anatomical knowledge to the situation of the more important branches. In addition to the main trunk, from two to four or six smaller vessels usually require to be secured : but sometimes, either from the existence of malignant disease, or of extensive suppuration in the limb, the stump is excessively vascular, and a very large number of ligatures may be required. I have, in these circumstances, more than once had occasion to apply between twenty aud thirty ligatures to vessels in the arm and thigh. Free arterial bleeding will sometimes take place from a point in the cut surface of the bone, in consequence of the division of the trunk of the nutrient artery. This h[Bmo]-rhage is best arrested by pressing into the canal one or two strands of narbolised catgut twisted together ; or, if this fail, it may be plugged with a small piece of carbohsed sponge, which will become buried in the stump and absorbed almost as easily as the catgut. The old plan of inserting a wooden plug with a wire to it should never be resorted to if other means are available, as it is certain to serve as a centre of suppuration, and it causes disturbance of the wound when it is removed. It is impossible to take too great care in arresting not only all arterial hsemorrhage, but all oozing of blood before closing the wound. It is to painstaking arrest of every trace of bleeding that the great success of some Surgeons in obtaining primary union is in part to be attributed. To have to open up the wound to secure a bleeding vessel within an hour of the operation is one of the most annoying accidents that can happen to a Surgeon, and is most damaging to the prospect of speedy union of the wound, but even this is less injurious than the distension of the flaps with a coagulum, the result of oozing which, perhaps, stops just short of obliging the Surgeon to open up the wound for its arrest. Before closing the. wound, the large nerves should be drawn out aud cut short with scissors to prevent their becoming implicated in the superficial scar. Any projecting tendons should be cut short in the same way. Closure of tlie Wound.—The hgemorrhage having been arrested, the covering is brought together over the bone by means of sutures. In a well- made stump the covering is so loose that no force is necessary to bring the edges together ; consequently, adhesive plaster can never be required. In cases in which a strictly antiseptic dressing is being used, unwaxedsilk boiled for half an hour, and then soaked for twenty-four hours in a 1 in 20 solution of carbolic acid, makes the best sutures. If the dressing is such that decomposi- tion of the discharges is possible, it is better to use silkworm gut, horsehair, or metallic sutures, as they do not absorb the septic matter, and are consequently quite unirritaLing if they are not tight. In inserting the stitches, it is better to put in two or three thick sutures, either of silk or wire, at intervals of about one inch to one inch and a half (Fig. '21). They should get a good hold of the skin and fat for at least one inch from the edge of the wound. These bear any strain that may arise from swelling or retraction. Between them finer sutures must be inserted, at intervals of about half an inch, bringing the skin edges into accurate apposition. Such close sewing as this, however, would somewhat endanger primary union, unless a proper exit for tiie discharges were provided for by drainage tubes. These are best made of india-rubber. One may be inserted in each angle of the wound, and, if it seems necessary from the size of the stumjj, a third may be placed in the middle. Drainage- tubes must be cut \evel with the surface of the wound, and above all it must$