The abstractor would suggest the application of this method, particularly in recent cases and in children, without the previous resection of a rib. The increased support afforded the canula by the greater thickness of the thoracic walls would be a still greater safeguard against the entrance of air into the pleural cavity. A certain proportion of acute cases will recover without resection of a rib.
WOUND-HEALING UNDER THE DRY ASEPTIC SCAB.
Prof. Kuester (Centralblatt f. Chirurgue, March 17, 1888,) in reply to remarks made by Dr. Sonnenberg before the Association of Berlin Surgeons, January 9, who characterized K’s method of treating the wound after the operation for the radical cure of hernia as an “open method,” objects to this designation of his method, and takes occasion to more fully describe his method as follows: After the reduction of the contents of the sac, the latter is sutured and excised, and the ring is also closed by suturing. The wound cavity itself is now closed by several rows of buried sutures, so arranged as to bring together the edges of the several layers, tissue to like tissue. In congenital cases he does not loosen the sac, but sutures its opposing surfaces down to the point where the testicle lies free. The wound of the skin is now closed by a continuous silk suture, and an iodoform and collodion mixture brushed over the line of suturing until it is perfectly covered in and blood no longer oozes through. No drain is used, and no further dressing is deemed necessary. If, after two or three days, a split occurs in the scab or crust formed by the drying of the iodoform and collodion, the gap is quickly filled by a slight oozing from the deeper portions of the wound, which, upon drying, becomes a bar against infection.
There can be no doubt, if thorough asepsis is observed and obtained during the operation, the method of completely obliterating every space in which blood clot or serum could accumulate would do away with the necessity for drainage. This granted, it follows, as a natural sequence, that absorbent dressings are superfluous, simple protection of the line of suturing from atmospheric influences, infection, etc., being alone indicated. The iodoform and collodion compound would seem to fulfil this admirably. The method could scarcely find application in large or deep wounds, particularly if the latter invaded planes of dense connective tissue, fasciæ, etc. Here it would be manifestly best to provide drainage, etc.
In marked contrast to K’s method is that of McBurney, who, providing against infiltration by suturing the entire thickness of each edge of the wound together in such a manner as to render it practically but one layer, packs the wound cavity, and thus obliterates the inguinal canal, the latter filling up by granulation, a firm cicatricial plug taking its place.
THE TREATMENT OF CAROTID HÆMORRHAGE.
Mr. Frederick Treves (The Lancet, January 21, 1888). In the neck, pressure upon the carotid artery, in hæmorrhages from the branches of that vessel, cannot be applied in the ordinary way with success, nor could it be maintained for a sufficient length of time, if the pressure succeeded in arresting the hæmorrhage, to be of service. Treves proposes, however, to occlude the vessel temporarily by throwing a broad piece of catgut around it, tying it in a loose loop, and then making traction upon the same. The circulation through the vessel is at once arrested, but can be at once restored upon relaxing the tension upon the loop. He relates four cases in which the method proved successful, so far as the arrest of the bleeding was concerned. One of the patients succumbed to the great loss of blood sustained prior to the application of the ligature, although the other carotid had been previously tied. In the first case the loop remained in situ for four days. The second case was the fatal one. In the third and fourth cases the loop was removed on the seventh day.
The method is based upon the fact that temporary arrest of the circulation in certain cases of hæmorrhage from the limbs, where ordinary means may be employed to exercise pressure, are quite sufficient, not only for the purposes of a temporary expedient, but also seems as a curative measure. This temporary modification of the blood current may be all that is required in many instances. Just how long the blood current may need to be checked, must be carefully studied in each individual case. The thought occurs to us, however, that some risk may be run of setting up an ulcerative action in the vessel walls by the prolonged application of a loose ligature, upon which must be exercised an intermittent pressure, by the pulsation of the vessel itself.
ARTIFICIAL AID IN THE FORMATION OF CALLUS.
Prof. Helferich (Archiv. f. Klinische Chirurgie, Band 36, 4. Heft, 1888). In cases of delayed union, and even in normal cases, to hasten the natural process of repair, H. advises the application of an elastic rubber bandage in such a manner as to retard the return flow of venous blood, by this means favoring an increased amount of pabulum to the field of repair, thus indirectly augmenting the formation of callus. The patient must be taught to regulate the pressure, attention being directed to the condition of the nails, in order that the bandage may be adjusted to suit the varying condition of congestion present. Œdema may be controlled by the application of a flannel bandage to that portion of the limb below the site of fracture. It is claimed that by this method the cure, in normal cases even, is considerably shortened. The process of repair is hastened by keeping the limb in a dependent position. The presence of small erosions at the site of fracture is not a contra-indication to the use of the elastic band. The time of application is of some importance, a too early application leading to too active hyperæmia; while, on the other hand, if too long delayed, the period of time in which the action will take place has passed. In wired compound fractures and in resections, pressure may be applied in from five to fourteen days after the operation, providing inflammatory symptoms are absent.