PLASTIC AND
COSMETIC SURGERY

“Father of Plastic Surgery.”

PLASTIC AND
COSMETIC SURGERY

BY
FREDERICK STRANGE KOLLE, M.D.
FELLOW OF NEW YORK ACADEMY OF MEDICINE; MEMBER OF DEUTSCHE MEDEZINISCHE
GESELLSCHAFT, N. Y., KINGS COUNTY HOSPITAL ALUMNI SOCIETY,
AUTHORS’ COMMITTEE AMERICAN HEALTH LEAGUE, PHYSICIANS’
LEGISLATURE LEAGUE ETC.; AUTHOR OF “THE X-RAYS:
THEIR PRODUCTION AND APPLICATION,” “MEDICO-SURGICAL
RADIOGRAPHY,” “SUBCUTANEOUS
HYDROCARBON PROTHESES,” ETC.

WITH ONE COLORED PLATE AND FIVE HUNDRED AND
TWENTY-TWO ILLUSTRATIONS IN TEXT

NEW YORK AND LONDON
D. APPLETON AND COMPANY
1911

Copyright, 1911, by
D. APPLETON AND COMPANY

PRINTED AT THE APPLETON PRESS,
NEW YORK, U. S. A.

TO
ALPHONZO BENJAMIN BOWERS
WHO KINDLED THE FIRE OF MY AMBITION
AND KEPT IT BURNING BY
HIS INTEREST AND UNTIRING APPRECIATION
THIS WORK IS
WITH HEARTFELT GRATITUDE
INSCRIBED

PREFACE

The object of the author has been to place before the profession a thoroughly practical and concise treatise on plastic and cosmetic surgery. The importance of this branch of practice is at the present time undeniable, yet the literature on this subject is widely scattered and scanty. It consists mostly of small, detached papers or reports in different countries, with an occasional reference in text-books on general surgery.

The author feels, from the numerous inquiries made him by physicians from many parts of the world concerning methods herein described, that there is now an actual need for an authoritative work on this subject.

Great care has been taken to select the best matter and to present it with comprehensive illustrations every physician can readily and confidently refer to.

Skin-grafting has been particularly gone into, as well as electrolysis as applied to dermatology, with information as to the construction and scientific use of apparatus involved.

To the whole has been added the practical experience and criticism of the author, who has devoted many years to the scientific and faithful advancement of this specialty.

Frederick Strange Kolle.

12 East Thirty-first Street,
New York City.

CONTENTS

LIST OF ILLUSTRATIONS

Transcriber’s Note: Some illustrations have been moved to where they fit best with the surrounding text. Links lead to the illustration, not to the page number.

PLASTIC AND COSMETIC SURGERY

CHAPTER I
HISTORICAL

It seems almost incredible that at this late day so little is generally known to the surgical profession of the beautiful and practical, not to say grateful, art of plastic or restorative surgery, successfully practiced even by the ancients.

The progress of the art has been much interrupted. It is only the later methods of antisepsis, which have so greatly added to general surgery, that have placed it firmly upon the basis of a distinct and separate art in surgical science.

To Aulus Cornelius Celsus, a Latin physician and philosopher, supposed to have lived in the time of Augustus, we owe the first authentic principles of the science. He was a most prolific writer and an urgent worker. After having introduced the Hippocratic system to the Romans he became known as the Roman Hippocrates. His best-known work handed down to us is the “De Medicina,” the first edition of which, divided into eight books, appeared in Florence in 1478. The seventh and eighth volumes, designated the “Surgical Bible,” contain much valuable data in reference to opinions and observations of the Alexandrian School of Medicine.

In considering plastic operations about the face (Curta in auribus, labrisque ac naribus) he writes, “Ratio curationis ejus modi est; id quod curtatum est, in quadratum redigere; ab interoribus ejus angulis lineas transversas incidere, quæ citeriorem partem ab ulteriore ex toto diducant; deinda ea quæ resolvimus, in unum adducere. Si non satis junguntur, ultra lineas, quas ante fecimus, alias dua lunatas et ad plagam conversas immittere, quibus summa tantum cutis diducatur, sic enim fit, ut facilius quod adducitur, segui possit, quod non vi cogendum est, sed ita adducendum ut ex facili subsequatur; et dimissum non multum recedat.”

Centuries elapsed before a clear understanding of the above was deduced. Several analyses have been advanced, those of O. Weber and Malgaigne being the most generally accepted.

As shown in [Fig. 1] the method advanced is one for the restoration or repair of an irregular defect about the face in which two transverse incisions forming angular skin flaps, dissected from the underlying tissue, are advanced, joining the denuded free ends.

Should there be a lack of tissue to accomplish perfect coaptation a semilunar incision beyond either outer border is added, as shown in [Fig. 2], which permits of greater traction, leaving two small quatrespheral areas to heal over by granulation:

Fig. 1.—Celsus Incision for Restoration of Defect.

Fig. 2.—Celsus Incision to Relieve Tension.

This is the oldest known reference to plastic surgery of times remote.

From the Orient, however, Susrata in his Ayur-Veda, the exact period of which is unknown, discloses the use of rhinoplastic methods.

For centuries following, and throughout the middle ages, the art seems to have waned and remained practically unknown, as far as is shown in the literature of that period.

A revivalist first appeared about the middle of the fifteenth century in the person of Branca, of Catania, a Sicilian surgeon, who about 1442 established a reputation of building up noses from the skin of the face (exore). His son Antonius enlarged upon his methods and is said to have utilized the integument of the arm to accomplish the same result, thus overcoming the extensive scarring of the face following the elder’s mode. He seems to have been the first authority employing the so-called Italian rhinoplastic method. He is also known to have ventured, more or less, successfully in operations about the lips and ears.

Balthazar Pavoni and Mongitore repeated these methods of operative procedure with more or less success and the brothers Bojanis acquired great celebrity at Naples in the art of remodeling noses.

Vincent Vianeo followed the work of the above.

But, somehow, the heroic efforts of these men dropped so much into oblivion that Fabricius ab Aquapende, in writing of the rhinoplastic work of the brothers Bojani, of Calabria, says: “Primi qui modum reparandi nasum coluere, fuerunt calabri; deinde devenit ad medicos Bononienses.”

That Germany was interested at an early date is shown in the admirable work of a chevalier of the Teutonic Order, Brother Heinrich Von Pfohlspundt, who wrote a book on the subject entitled “Buch der Brundth Ertznei,” with a subtitle, “Eynem eine nawe nasse zu mache.” His volume appeared in 1460, about the time of Antonio Branca, of whose methods he was ignorant, claiming to have learned the art from an Italian who succored many by his skill.

Between the years of 1546 and 1599 Kaspar Tagliacozzi, Professor at Bologna, followed the art of rhinoplasty. His pupils published a book at Venice, describing his work in 1597, entitled “De Corturum chirurgia per insitionem,” which established the first authentic volume in restorative surgery. His operation for restoring the entire nose from a double pedicle flap taken from the arm was declared famous and the operation he then advocated still bears his name.

The great Ambroise Pare knew little of rhinoplasty except what he learned from hearsay. As an instance, he relates in 1575 that “A gentleman named Cadet de Saint-Thoan, who had lost his nose, for a long time wore a nose made of silver and while being much hurt by the criticisms and taunts of his acquaintances heard of a master in Italy who restored noses. He went there and had his facial organ restored, and returned to the great surprise of his friends, who marveled at the change in their formerly silver-nosed friend.”

Now again came a century of forgetfulness, the scientific world taking no cognizance of the work done until, suddenly, in 1794, a message came from Poonah, India, to the effect that an East Indian peasant named Cowasjee, a cowherd following the English army, was captured by Tippo Sahib, who ordered the prisoner’s nose to be amputated. His wounds were dressed and healed by English surgeons. Shortly after this the victim of this odd mode of punishment was befriended by the Koomas, a colony of potters, or, as others claim, a religious sect, who knew how to restore the nose by means of a flap taken from the forehead. They operated on him and restored his nose much to the surprise of Pennant, who reported the case in England.

Shortly following this, and in the same year, cases of similar nature are described in the Gentlemen’s Magazine (England), and Pennant’s “Views of Hindoostan.”

In 1811 Lynn successfully accomplished the operation in a case in England, and in 1814 Carpue published his results in two cases successfully operated by him by the so-called Hindoo method.

France now took up the art of rhinoplasty. Delpech introduced a modification of the method of the Koomas in 1820, while Lisfranc performed the first operation of this nature in Paris in 1826.

In 1816 Graefe, of Germany, took up the work of Tagliacozzi but modified his method by diminishing the number of operations.

Bünger, of Marburg, thereupon, in 1823, successfully made a man’s nose by taking the necessary tegument from the patient’s thigh.

A still later modification in the art of rhinoplasty was that of Larrey, who in 1830 overcame a large loss about the lobule of the nose by taking the flaps to restore the same from the cheeks.

Among the better advocates of reparative chirurgery were Dieffenbach, v. Langenbeck, Ricard, v. Graefe (1816), Alliot, Blandin, Zeis, Serre, and Joberi, while Thomas D. Mutter, in 1831, published the results he obtained in America—his co-workers being Warren and Pancoast.

Although Le Monier, a French dentist, as early as 1764 originally proposed closure of the cleft in the soft palate, no one attempted to carry out his suggestion until in 1819 the elder Roux, of Paris, performed the operation. The following year Warren, of Boston, independently decided upon and successfully did an improved operation to the same end.

During the years 1865-70 Joseph Lister distinguished himself in the discovery and meritorious employment of carbolic acid as a means of destroying, or at least arresting, infectious germ life, the principle of which, now so fully developed, has advanced the obtainable surgical possibilities inestimably.

The credit of first collecting data of plastic operations belongs to Szymanowski, of Russia. In his magnificent volume of surgery (1867), he embodies a somewhat thorough treatise on restorative surgery, leaving the subject to be treated more fully and independently, as it should be, to some other enthusiastic surgeon specialist. His work is the result of careful study of such operations on the cadaver, a method much to be recommended to the prospective or operating plastic surgeon.

Several years later, 1871, Reverdin added a valuable method to the still incomplete art, by introducing the now well-known circular epidermal skin grafts for covering granulating surfaces. Thiersch improved this method in 1886 by showing that comparatively large pieces of skin could be transplanted. Wolfe, of Glasgow, had also been successful in utilizing fairly large skin grafts.

Krause, however, improved upon all of these methods by transplanting large flaps of skin without detaching the subcutaneous tissue, a procedure which causes more or less injury to the graft in other methods, and by his method overcoming the subsequent contraction, heretofore a bad feature when the skin-grafted area had healed.

“The results of most plastic operations have been as satisfactory as the most sanguine could hope for or the most critical expect,” says John Eric Erichsen.

Many important additions have been made in the past few years—the outcome of untiring attempt and skill. Czerny replaces part of an amputated breast with a fatty tumor taken from the region of the thigh. Glück successfully repairs a defect in the carotid artery with the aid of a piece of the jugular vein. Glück, Helferich, and others have advocated implanting muscular tissue taken from the dog into muscular deficiencies in the human, due to whatever cause.

The transplantation of a zoöneural section into a defect of a nerve in the human was successfully accomplished by Phillippeaux and Vulpian.

Glück, who later restored a sciatic nerve in a rabbit by the transplantation of the same nerve taken from a hen, went so far as to restore a 5-cm. defect of the radial nerve of a patient by the employment of a bundle of catgut fibers, fully establishing the function of the nerve within a year’s time.

Guthrie has successfully replaced the organs and limbs of animals and has actually transplanted the heads of two dogs.

The transplantation of a toe, to make up a part of a lost finger, is proposed by Nicoladoni. Van Lair hints at the possibility of removing a part or a whole organ immediately before death to repair other living organs.

Von Hippel has successfully implanted a zoöcorneal graft from a rabbit upon the human eye, and Copeland has taken the corneal graft from one human and transplanted it upon the cornea of another to overcome opacity.

The transplantation of pieces of bone to overcome a defect of like tissue has been fully investigated by Ollier, v. Bergman, J. Wolff, MacEwen, Jakimowitsch, Riedinger, and others. They discovered that a graft of bone, with or without its periosteum, can be made to heal into a defect when strict antisepsis is maintained.

Von Nussbaum was the first to introduce the closing of an osseous defect by the use of a pedunculated flap of periosteum.

Poncet and Ollier employed small tubular sections of bone, while Senn has obtained excellent results from the use of chips of aseptic decalcified bone.

Hahn succeeded in implanting the fibula into a defect of the tibia.

On the other hand, cavities in the bones have been successfully filled by Dreesmann and Heydenreich with a paste of plaster made with a five-per-cent carbolic-acid solution, and at a later period by the employment of paraffin (Gersuny) and iodoform wax, as advocated by Mosetig-Moorhof.

The thyroid glands taken from the sheep, it is claimed, have been successfully implanted in the abdomen of individuals whose thyroid glands had been lost by disease or otherwise.

Protheses of celluloid compound or gutta-percha and painted to resemble the nose or ear have been introduced with grateful result. Metal and glass forms have been used to replace extirpated testicles or to take the place of the vitreous humor of the eye (Mule).

Sunken noses have been raised with metal wire, metal plates, amber, and caoutchouc. Metal plates have been skillfully fitted into the broken bony vault of the cranium.

Lastly comes Gersuny’s most valuable method of injecting paraffin compounds subcutaneously for the restoration of the contour of facial surfaces and limbs, which is rapidly taking the place of extensive plastic transplantory and the much-objected-to metal and bone-plate operations for building up depressed noses and other abnormal cavities.

And the end of possibilities is not yet reached. The successful plastic surgeon has become an imitator of nature’s beauty to-day.

His skill permits of many almost unbelievable corrections of defects that would otherwise evoke the pity and too often the aversion of the onlooker, especially if these occur in the faces of those that have become marred in birth or age, by accident or disease. Withal, it is a noble, generous art, worthy of far more extensive use than it now enjoys.

The above fragmentary references include a number of plastic possibilities. They are introduced only in the sense of general interest to the cosmetic surgeon, the special and detailed subject matter herein given under the various divisions have to do only with plastic and cosmetic operations about the face.

CHAPTER II
REQUIREMENTS FOR OPERATING

THE OPERATING ROOM

The ideal operating room for the plastic surgeon need not necessarily be large, since it requires less work to render it aseptic. Furniture and possibly amphitheater accommodation are always a means of infection unless scrupulously cleansed, a task of time, difficult at best.

The room should be provided with large windows, with facilities for the introduction of the air from without. Two doors, and those well fitted, are all the room should have—but one being used, if possible.

The Walls.—The walls should be of plaster, smoothly laid and well painted, so that they may be readily washed down with antiseptic solutions—a daily morning rule. Glass or tiled walls are much used now and add considerably to the appearance and safety of the room, as plaster in time will crack, while the paint, owing to the heat of sterilizers or steam, often creeps and blisters, exposing an absorbing surface which readily wears down, exposing parts inaccessible for even acute cleanliness.

The Floors.—The floors of these rooms are now usually laid with tile mosaic or marble or a composition resembling linoleum. The base should be curved and all corners sloped off to improve drainage and to keep off dust and dirt.

Skylight.—A skylight of metal and glass is a valuable accessory. It should be fixed or never permitted to be opened during an operation.

Disinfection.—Spraying the room with an antiseptic is hardly necessary, since all germ life descends to the floor and can best be removed by washing with a 1-1000 bichlorid solution.

Should it be necessary to perform an unusually extensive operation in a private house, the room must be cleared of all furniture, pictures, drapery, and carpet. After plugging up the crevices in the windows and doors it should be well fumigated either with sulphur candles, as now commonly furnished, or, better, with formaldehyd.

The superiority of formaldehyd as a disinfecting agent is now well established. An illustration of an apparatus, largely doing away with the difficulties and dangers encountered in the use of the older and ordinary styles of the pressure or nonpressure type, is shown in [Fig. 3]. The main difficulty with these has always been their almost inaccessibility for cleansing purposes, and in such where this is not the case, the size of the aperture has been made so small that the inside could not be reached. In the pressure apparatus the tops are bolted on, making them exceedingly difficult to remove, with the result that the necessary cleaning was not properly attended to. The corrosive action of formaldehyd gas is such that under these conditions any apparatus would soon become useless.

In the type shown a single clamp arrangement is used (a). By the turning of the hand screw (b) two planed metal faces (the upper surface of the boiler and under surface of the cover) are brought together and sealed. When the cover (c) is removed the entire inside of the boiler is in sight and can be thoroughly cleansed, which should be done each time the apparatus is used. The pipes through which the formaldehyd gas passes after generation are arranged so that they can be taken off and cleaned.

Fig. 3.—Formaldehyd Disinfecting Apparatus.

The gas is generated in the boiler (d) and passes out from the top, down through the pipe (e), and from thence through a series of pipes (f) underneath the boiler, which are subjected to direct heat from the lamp (g). By this means the gas becomes superheated, the polymerization of the formaldehyd is almost entirely prevented, and a dry gas is insured and given off at the pipe (h).

The room should be left closed overnight and thoroughly aired thereafter. The bare floor must then be scrubbed with hot water and soda and flushed with a three-per-cent carbolic-acid solution.

As little furniture as possible should be found in an operating room, and this preferably of undecorated enameled iron.

Instrument Cabinet.—For the instruments and dressings there should be a dust-proof cabinet of iron and glass, such as is shown in [Fig. 4].

Fig. 4.—Instrument Cabinet.

Operating Table.—The operating table should be of like construction and as plain as possible. Its top can be padded with sterilized felt, protected from moisture by rubber sheets. A surgical chair of plain construction might suffice, inasmuch as most plastic operations cover but a small area and are usually about the head and often performed under local anesthesia. A chair with head rest is much more comfortable, adding much to the moral and physical comfort of the then conscious patient. A very desirable chair is shown in [Fig. 5].

Fig. 5.—Operating Table.

Instrument Table.—An instrument table, such as is shown in the next illustration, is quite necessary, upon which dressings and instruments are laid during operation. In this the frame is of white enameled iron and the top and shelf of plate glass.

Fig. 6.—Instrument Table.

Irrigator.—An irrigator is often of service, especially in washing out the fine pieces of bone resulting from chiseling or drilling. In skin-grafting it may be used with sterilized three-per-cent salt solution as described later. The best irrigators are those of germ-proof or ground-glass stopper type. They are suspended from the wall by means of an iron bracket or pulley service or placed upon a movable enameled stand as shown in [Fig. 7].

Irritating antiseptic solutions are to be avoided, their especial indication will be found under antiseptic care of wounds.

CARE OF INSTRUMENTS

Fig. 7.—Irrigator.

All instruments should be of modern make, devoid of clefts or grooves, and having separating locks when possible. Wooden or ivory handles should be entirely discarded. They should first be rendered free of dirt or dried blood by scrubbing briskly with a stiff nailbrush and hot water; then dried and placed in the sterilizer. The immersed instruments are boiled for five or ten minutes. There are many of such sterilizing apparatuses to be obtained, all made on the same plan, however, and consist of a copper or brass box and cover well nickel plated. Folding legs are placed beneath. A perforated tray is placed within for the immersion of instruments. An alcohol lamp with asbestos wick furnishes the heat.

One per cent of carbonate of soda added to the water prevents them from rusting. The simple subjection of instruments to carbolic-acid solutions or antiseptics of like nature is useless. (Gärtner, Kümmel, Gutch, Redard, and Davidsohn.)

From the sterilizer the instruments are placed in a glass tray containing a one-per-cent lysol solution. Knives, needles, and scissors should be immersed in a tray with alcohol, as a great number of antiseptics destroy their cutting edges. Glass or porcelain trays are best for this purpose. A sterilized towel being placed in the bottom of each for the better placing of instruments.

After operation all instruments should again be scrubbed with soap and hot water, immersed a moment in boiling water or a jet of live steam, dried with an aseptic cloth, and returned to the case.

A very effectual means of rendering instruments sterile is to place them in a metal box and bake them in the ordinary oven (200° F.) for one hour.

To preserve needles Dawbarn advises keeping them in a saturated solution of washing soda. Albolene has an unpleasant oiliness, but is otherwise good. Calcium chlorid in absolute alcohol is efficacious, but expensive. All rust accumulating on instruments must be carefully removed with fine emery cloth; this, however, is unnecessary if the soda solution is used as previously mentioned. It is well to occasionally dip the instruments (holding them with an artery forceps) into boiling water as they are used during operation.

Fig. 8.—Instrument Sterilizer.

PREPARATION OF THE SURGEON AND ASSISTANTS

Care of the Hands

The hands of the surgeon and his assistants must always be thoroughly prepared before operation or dressing a wound. The mere immersion of the hands into an antiseptic solution is not sufficient to remove germ life. The oily secretions of the skin and its folds, as well as the cleft about the nails and the nails themselves, are common carriers of infection and are cleansed only by the vigorous method of scrubbing with soap and water and then rendered aseptic by the use of proper media.

The aseptic hospital washstand, as shown in [Fig. 9], will be found an ideal piece of furniture; it has a frame constructed of wrought iron, white enameled. The top is of one-inch polished plate glass, with two twelve-inch holes.

Fig. 9.—Aseptic Washstand.

The entire stand can be moved away from the wall, to permit of thorough cleaning of basins, supply pipes, etc. The basins are the best annealed glass, and are supported by nickel-plated traps, with connections for vent pipes. The water supply is controlled by foot valves, which enable the operator to draw either cold, medium, or hot water at will. The waste is also controlled by a foot valve, as shown.

The systematic law of cleansing the hands should be insisted upon at all times. Rules for the method followed might be displayed in abbreviated form in the operating room by glass or enameled signs hung on the wall over the basin and reading as follows:

YOUR HANDS

Green soap is commonly used and is to be preferred to powdered or cake soap. The powder cakes and clogs the container in damp weather, while the latter collects impurities from the air. Synol soap, also liquid, is perhaps the most ideal, a two per cent solution of which forms an excellent lavage for cleaning instruments, as well as washing down furniture in the operating room.

The brushes to be used are of the common wooden-back, hard-bristle make, which can be boiled without injury. There should be several of these, marked on their backs as desired, so that one brush can be used for the one purpose only. In cleansing the hands, the forearms, and even the elbows, should be similarly treated. After scrubbing with soap, as directed, they are to be rinsed, dried with a sterilized towel, again scrubbed with alcohol, and then dipped or flushed with a bichlorid solution.

Gowns

No woolen garments should be allowed to come in contact with the site of the operation, nor is it well to allow such material in the operating room while working.

Freshly laundered linen gowns of Von Bergman’s pattern, reaching to the shoes, should be worn. They should contain half sleeves and be buttoned on the back. See [Fig. 10]. These may be sterilized in the steam sterilizer or washed in one-per-cent soda solution. When soiled or blood-stained they should be relaundered.

The operator may substitute the gown with a rubber apron of the Triffe pattern, reaching as high as the collar, but continuous washing quickly ruins them. See [Fig. 11].

Fig. 10.—Von Bergman Operating Gown.

Fig. 11.—Triffe Rubber Apron.

PREPARING THE PATIENT

General Preparation

The patient for all plastic operations should be carefully examined as to general health and past history. His healing powers should be at their best, as much depends on primary union. If he presents a syphilitic history, it is well to place him under treatment, for a time, at least, before an operation is undertaken. The bowels should be regular. Sulphate of magnesium should be given each morning, before breakfast, for at least two days prior to operating, while his general condition may be improved by the employment of bitter and alterative tonics. Nux vomica with tinct. cinchonæ com., associated with essence of pepsin aromat., or lactopeptone, are very useful. This treatment is also carried on for several days, post operatio.

The success of an operation depends, first, upon the selection of the case; second, the selection of the method employed, and, third, upon the hygiene under which the patient undergoes convalescence. The patient must be given to understand, in many cases, that it is often necessary to reoperate, even to the extent of seven or eight operations, to bring about the desired result. The first result obtained with many cosmetic operations is not at all gratifying to the patient, and unless this is explained to him beforehand he may become discouraged awaiting the next operation and disappear, thus losing the opportunity of being pleased finally, while the surgeon is misunderstood and underestimated by narrow-minded judges and the ever-willing friendly advisers and critics—a consummation much to be avoided.

Preparation of the Operative Field

The part to be operated upon should first be closely shaven. The oily secretions of the area are next rubbed off with an absorbent cotton sponge saturated with alcohol or ether. Next, the skin is washed with hot water and soap or three-per-cent synol suds, then rinsed, and finally rendered aseptic with a bichlorid solution.

If the operation is to be done about the face a rubber cap is so adjusted as to cover the hair. If this is not obtainable sterilized bandages can be employed.

In operations about mucous membranes, as in the nose and mouth, the parts must be cleaned at short intervals with a solution of permanganate of potash or boric acid. The teeth must be cleansed with antiseptic soap, tartar is scraped off, and the mouth rinsed with a proper disinfectant. The corrosive sublimate, or carbolated solutions, owing to their toxic qualities, cannot be used. The preparation of wounds for reoperation, or where an operation is secondary to injury, is referred to later.

All clothing about the site of operation should be removed and rubber cloth placed to surround the field and cover the clothing. This should be covered again with sterilized towels. Everything that touches the patient after this has been done should be aseptic; indeed, hands employed during operation must be immersed from time to time in 1-500 bichlorid solution, and allowed to remain wet.

CHAPTER III
REQUIREMENTS DURING OPERATION

SPONGES AND SPONGING

Natural or sea sponges are now little used in surgery, owing to their peculiar cellular construction. They invite and readily retain spores and germs, are difficult to clean, and require almost constant attention to be at all safe.

Many methods for rendering these sponges aseptic have been proposed, but at best the life of such a sponge is short and hardly pays for the labor and time expended. The absorbing power of a sponge is, of course, its essential quality. For plastic operations sterilized absorbent cotton made into small balls answers every purpose. These puffs of cotton are covered with gauze to prevent the fraying out of the fibers. To further improve them, their centers may be made up of cellulose or wood fiber. When an absorbent cotton sponge is moistened and squeezed out it does not answer as well, since its absorbing qualities are much reduced; the addition of the other material overcomes this.

A much-used and inexpensive sponge having great absorbing power is made in the form of a small compress of sterilized gauze held together with one or two stitches of thread. All of the above sponges are sterilized with the needed dressings and are burned after use. When removed from the sterilizer they are placed in a suitable basin containing six per cent sterilized salt water. It is well to place the receptacle close by the assistant who is to sponge. An enameled iron basin rack, as shown in [Fig. 12], answers the purpose best.

Fig. 12.—Basins and Rack.

The soiled sponges are thrown into a lower empty basin or one placed at the operator’s feet. As they are removed from the solution they are squeezed as dry as possible and pressed upon, rather than wiped across, the operative field. It must be remembered that the surgeon’s work must not be hampered by slow or inefficient sponging, and that this procedure must be quick and timely. It is well for the assistant to become accustomed to the habit of the operator.

The best assistant is one who has acquired a methodical and regular manipulation, a result dependent upon constant individual association; such a one is practically invaluable for the skillful performance of plastic surgery. He becomes not only familiar with the one thing, but cultivates a ready knowledge of the arrest of hemorrhage by digital compression when hemostatic forceps would hinder the ease of work, besides cultivating a happy manner of holding retractors or spreading the edges of the incisions with the free hand. As in most of these operations hemorrhage cannot be controlled by the so-called bloodless method. The assistant must control the constant oozing by the gentle pressure of the sponge quickly applied at short intervals. When the sponges are squeezed out in salt solution, as hot as the hand will bear comfortably, capillary oozing is more readily overcome.

STERILIZATION OF DRESSINGS

All dressings to be used in covering wounds, post operatio, or otherwise, must be as scrupulously clean and free from infection as the hands and the instruments of the operator. This is done by means of sterilization by dry heat or steam under pressure. For all minor cases, small apparatuses only are needed. They are usually made of copper, often nickel-plated, and so constructed as to contain a lower perforated instrument tray and another, placed above it, for dressings. The two are fitted into an outer copper receptacle with snugly fitting cover. A folding stand is furnished upon which this arrangement is placed, and an alcohol lamp with asbestos wick furnishes the heating power. The lower tray is covered with water which, by boiling, fills the upper compartment with steam evenly distributed and with sufficient pressure to accomplish sterilization in from thirty to sixty minutes. Metal hooks are provided with which the trays can be removed. A complete and compact outfit, as designed by Willy Meyer, is shown in [Fig. 13].

In the above sterilizer, or in those of similar type, there is naturally more or less saturation of the dressings and the possibility, in the event of the entire conversion of the water contained therein into steam, of injuring the instruments by excessive heat. To overcome this defect the Wallace sterilizer may be advantageously employed.

Fig. 13.—Willy Meyer Sterilizer.

Fig. 14.—Wallace Sterilizer.

Wallace Sterilizer.—Its chief feature is the addition of a reservoir fitting with the separated sterilizer into the outer body. See [Fig. 14]. This reservoir automatically regulates the water and steam supply. It is filled with water and inserted into the compartment provided for and adjoining the sterilizer. Through an opening in the bottom the water is permitted to escape into the sterilizer until the bottom of the latter is covered to a depth of ⅛ inch. As the heat is applied from the alcohol lamp this film of water is rapidly converted into steam.

The dressings arranged in the large tray are placed in the sterilizer and the supply of steam is maintained through the constant and steady flow of water from the reservoir, which compensates the evaporation in the sterilizer. In about twenty minutes the formation of steam in the top of the reservoir exerts sufficient pressure to force all the boiling water from the reservoir into the sterilizer to the depth of about 1½ inches. The tray of instruments is now inserted and the process continued for another ten minutes. Much less heat is required with this apparatus than with those of ordinary type, while sterilization can be continued uninterruptedly for one and one half hours, if need be.

Sprague Sterilizer.—The most perfect sterilizer is that of the Sprague type, in which a dry chamber is surrounded by steam under pressure. The apparatus is shown in [Fig. 15].

Fig. 15.—Sprague Type of Sterilizer.

Its cylindrical chamber is surrounded by two heavy copper shells, the space between which is occupied by the water. This compartment is entirely shut off from the sterilizing chamber, and as the steam is generated, the inner, or sterilizing, chamber becomes heated to a degree nearly equal to that of the steam in the surrounding cylinder; this prevents any condensation of steam taking place in the dressings. By opening the lever-handled valve at the bottom of the sterilizer in the rear, and the valve to the right, on top of the sterilizer, and allowing them to remain open for a space of four or five minutes, a vacuum is formed in the sterilizing chamber. These two valves are then closed, the lower one first, and the steam from the outer cylinder is allowed to enter the chamber, by opening the left valve on top.

The contents should be allowed to sterilize for twenty or twenty-five minutes under a pressure of fifteen pounds. Then close the steam-supply valve; open the vacuum valve (right) and the lever-handled valve at the bottom; leave these open about the same time as in creating a vacuum at the beginning of the process; close both valves, then open the air-filter valve on the door, in order to break the vacuum; the door can then be opened and the dressings be taken out dry and absolutely sterile.

The steam-safety valve on this sterilizer is set at seventeen pounds, but it can easily be regulated should a higher or lower pressure be desired. The door used on this apparatus has no packing of rubber or other soft material which wears or shrinks in time, a steam-tight joint being formed by the bringing together of two plane metal faces on the door and sterilizer head. The door hinge is so made that these parts are bound to come together properly, without the use of excessive caution. Springs on such doors are liable to get out of order or need replacing, and are avoided in this apparatus. All that is necessary to lock or unlock the door is to turn the large hand wheel on the front; the locking levers then work automatically. These sterilizers are arranged for both gas and steam heat.

Sterilizing Plant.—For the ideal operating room the entire sterilizing plant can be had in combined form, as shown in [Fig. 16]. It consists of a dry-heat dressing apparatus, just described, water and instrument sterilizers, all mounted on a white enameled, tubular, wrought-iron frame. The chamber of the dressing sterilizer is 8½ by 19 inches. The water sterilizer has a capacity of six gallons in each tank and is fitted with natural stone filters, thermometer, water gauge, safety valve, etc. The size of the instrument sterilizer is 8 by 15 inches and 6 inches deep, with two trays. Each apparatus in the above can be used independently of the other, all being arranged for gas-heating.

Fig. 16.—Sterilizing Plant.

Dressing Cases.—All dressings should be sterilized immediately before operation, and not laid away for later use, as often done. As the aseptic material is taken from the sterilizer it is to be placed in glass cases provided therefor, from which they are removed, as needed, during the operation.

A simple glass case, as shown in [Fig. 17], may be used, or, better still, the same can be obtained in combination with an instrument table, as shown in [Fig. 18].

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:

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:

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:

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;

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.