Every suture which has failed of its purpose or ceased to be effective should be removed. Ordinarily they are left in place from four to ten days. They should be removed by dividing upon one side of the knot, which should be seized with forceps and pulled upward and to the other side. The suture should be cut at a point where it is moist, so that only its flexible portion may be drawn through the parts which it has held. Moreover the buried portion is more likely to be sterile. Secondary sutures are usually made of silkworm-gut, celluloid thread, or wire. So soon as they are found unserviceable they also should be removed.
Knots.
—The purpose of a knot is not achieved if it slips, and the “surgeon’s knot” is best for the purpose, since in the first formation one end is carried twice around the other before being tied in the opposite direction. It requires more force in making it taut, but it is safer than the ordinary reef knot ([Fig. 67]).
[Figs. 69] and [70] illustrate the clove-hitch, which becomes firmer the tighter it is pulled. It is rarely used in ordinary sutures or ligatures, but may be made exceedingly valuable. The Staffordshire knot ([Fig. 71]) serves especially for securing pedicles, which are first transfixed with a double thread, the loop thus formed being slipped over the stump and secured between the two loose ends of the ligature, one end being placed over and the other under it; each is pulled tightly and secured by an ordinary knot. When properly applied it is effective. When knots are improperly applied none of them should be trusted.
When wire sutures are used it is sufficient to twist the ends, unless very fine wire is used, when it may be tied.
CHAPTER XXIV.
ASEPSIS AND ANTISEPSIS; TREATMENT OF WOUNDS.
The medical student of the present generation has no conception of the contrast between the results of today and those of a generation ago, or before the introduction of antiseptic technique and its later perfection, asepsis. Under the term “antiseptic” should be included those measures intended to combat sepsis, or surgical infection, from without. The term asepsis is of later date, and was introduced when it was found that the prevention of infection was better than measures calculated to overcome it, or atone for its presence. A perusal of former surgical horrors will afford but an insufficient comparison as to the incalculable benefits for which we are indebted to a small group of men, of whom Lister is the most important; although the names of Pasteur and of Ogston should ever be held memorable in this connection. The two great nineteenth century achievements in surgery were anesthesia and antisepsis, both of Anglo-Saxon origin, one American, the other British.
It was the recognition of the parasitic, i. e., the germ nature of surgical infections, which led to Lister’s first attempts to exclude and combat the infecting agents. And while the original technique which he introduced has been changed in nearly every particular, the correctness of the views upon which it was based has been ever broadened and strengthened. We have learned that simple measures may be as effective as those more complicated, and the principal changes which have been made in three decades have tended toward simplicity and prevention. Thus heat has been made to take the place formerly occupied by carbolic acid. And we have learned that parts made clean need little antiseptic protection. We have learned that healthy tissues are endowed with large powers of self-protection, and also that this self-protection is interfered with by causes over which the surgeon has sometimes but little control. A wound in a body loaded with toxic products is by no means protected against infectious agents by mere external agencies. The appearance of pus in a wound is a reflection upon the surgeon. The ideal aseptic technique will include many days of local and constitutional protection, as has been stated in the sections on Auto-intoxication and on the Preparation of the Patient.
The methods of either antiseptic or aseptic technique include as a fundamental basis the necessity for perfect sterilization of everything which may come in contact with the wound, so far as the surgeon can control it. The atmosphere contains in suspension bacteria, but their contact is no longer dreaded, because of reliance upon the germicidal powers of the fluids and tissues of the body. It is known, however, that in accumulation of fluids there is danger as well to the tissues, either from rude handling, application of large pressure forceps, the insertion of too many stitches, or whatever else may lacerate or impair the circulation.
There are parts of the body where no precautions can afford complete freedom from germ activity, as in the mouth, the vagina, the rectum. Here the surgeon must be cleanly in his work, assuring himself that he introduces nothing new from without. Furthermore, after operation upon these parts he must ensure his precautions by the use of mouth-washes, douches, etc. On the other hand, ample opportunity should be afforded for sterilization of the field of operation, of the hands of the operator and his assistants, the instruments, ligatures, and dressings—everything which may come in contact with the raw surface.