QUILLED SUTURE.

So called from a quill being formerly used in making it. This means of uniting wounds has been occasionally practised, when the muscles have been deeply wounded, and it was employed on the supposition, that it produces a more perfect support of every part of a wound, than is effected by the preceding suture. The same kind of needle is used as for the interrupted suture: but, it must be armed with a double ligature. When the double ligatures have been introduced through the lips of the wound, at as many places as the length of the wound may require, their ends are to be separated, and then tied in a bow over a piece of bougie, quill, or any similar thing, placed along each lip of the wound.

Dionis first reprobated the adoption of this suture, and it is justly rejected by almost all the moderns, so that it is unnecessary to consider any of its modifications.

SUTURES NOT GENERALLY PROPER.

In the present schools of surgery, the use of sutures is not recommended as it was in former days. It is now known, that, by the combined operation of position, adhesive plaster, and a bandage, almost all wounds are capable of being united, as expeditiously, and well, as they could be, were sutures to be employed. Therefore, were it only to avoid superfluous pain, we ought to reprobate the practice in general. Did sutures only create a little additional pain, and no other evil, still their employment would be justifiable, if they really possessed the power of rendering union by the first intention, a matter of greater certainty, in only a limited proportion of cases, to which they are applied. In the cure of the harelip, and a few wounds of the face, and, perhaps, in the treatment of large wounds, penetrating the abdomen, we must admit their utility. In wounds of the lips, the incessant and unavoidable motion of the part; and, in those of the abdomen, the distention, arising from the viscera, and the danger of their being protruded, are reasons, which explain the advantage of sutures in these particular instances. But, in general, the promotion of union by the first intention cannot be set forth as a valid argument, in favour of sutures being commonly used. Inflammation, above a very moderate pitch, always destroys every prospect of this nature, and occasions the secretion of pus, instead of the exudation of coagulating lymph. Sutures have fallen into disrepute, principally, because they tend to increase inflammation. The new wounds, which they make, their irritation as extraneous

3

bodies, the forcible manner in which they drag the living parts together, and their incapacity, in general, to accomplish any useful purpose, which position, adhesive plaster, and bandages, cannot effect, are strong motives for reprobating their being commonly used. In fact, it often happens, when sutures are employed, that considerable inflammation of the wound is the consequence, and its swollen edges evince marks of suppuration, unless soon relieved from the irritation of the ligatures. In this case, if the surgeon is sagacious enough to cut the ligatures, and remove them in time, suppuration may still be frequently avoided. Extensive erysipelatous redness, surrounding wounds, will often be found to originate from the irritation of sutures.

M. Pibrac's remarks, on this subject, are highly worthy of universal consideration. After relating many convincing facts, he concludes with asking, what practice the partizans of sutures would adopt, were they necessitated, as they frequently are, to cut the ligatures, and remove them? Or, were they to find, as is often the case, that the ligatures had made their way through the lips of the wound, so as to leave them gaping? They would then never think of introducing new sutures, but would have recourse to a bandage, in order to unite the wound.*

They, who assert, that the good effect of sutures is, in many cases, supported upon the solid basis of experience, ought to prove, that the same effect could not be produced by the combined operation of a proper posture, adhesive plaster, and the pressure of bandages.

Whoever wishes to investigate this subject further should peruse M. Louis's observations on the first principle of the art of uniting wounds. This justly famous man proved, that even the harelip could be united very well without a suture.†

CHAP. XV.

PROCESS BY WHICH THE WOUND IS UNITED.

WHEN the opposite sides of an incised wound are maintained in contact by the foregoing means, they soon become perma

*Sur l'Abus des Sutures, in Mém. de l'Acad. de Chirurgie, Tom. 3, 4to, or Tom. 9, 12mo.

+ See Mémoire sur l'Opération du Bec-de-Lievre, op. cit. Tom. 12. p. 118. edit. 12mo.

nently connected together. The vessels of the wounded surface cease bleeding, and their extremities become impervious to the blood itself, but not to the coagulating lymph, which forms the general bond of union between living parts. This uniting medium is the primitive and most simple connexion, that takes place between the two sides of a wound. In many cases, however, where the wound is put into a state of apposition, before the hemorrhage has had time to cease, no doubt a coagulum of blood itself constitutes the first bond of union, and, wounds must thus be frequently united through the medium of red blood. I have, however, already explained, that the best practical surgeons prefer the plan of making the surface of the wound as free from blood as possible, before bringing the opposite sides of the injury into contact. It is found, that union by the first intention will more certainly follow this mode of proceeding. However, the reader is not to understand, that he is to defer bringing the sides of a wound together, until every little oozing of blood is at an end. The long exposure' of the wounded surface would be very injurious and tend to defeat the grand object in view, direct adhesion, without suppuration.

The simple agglutination of the sides of a wound together, is what may be considered as taking place directly they have been brought into contact. The next step, in the process of union by the first intention, is the generation of vessels in the coagulating lymph, or blood, and this is soon followed by an intercourse between the vessels of the two sides of the wound. The manner, in which the new vessels arise in the uniting medium, as well as the way, in which the inosculation of the divided vessels happens, are at present only matters of conjecture. Mr. Hunter conceived that blood and coagulating lymph, as long as they retained the living principle, possessed the faculty of generating vessels within themselves, quite independently of any adjoining surfaces. In the growth of the chick, there are some appearances in favour of this opinion.

The celerity, with which the process of union by the first intention is completed, is a circumstance that must excite the admiration of the philosophical surgeon. In the short space of seventy-two hours, the wound, produced by an amputation of the thigh, is often securely united through its whole extent, without any suppuration, except just where the ligatures are situated. Incised wounds, of a moderate size, may in general be completely healed by this method in forty-eight hours. How different then is the surgery of the present day to that of half a century ago, when the bigoted prejudices of our ancestors

deterred them from doing, not only what was most salutary, but most simple! The complicated business of accomplishing digestion, incarnation, and cicatrization, is now reduced to the easy duty of bringing the edges of a clean cut wound into contact, and maintaining them so, until they have grown together.

CHAP. XVI.

PUNCTURED WOUNDS.

PUNCTURED wounds are not only dangerous, on account of their frequently extending to a considerable depth, and injuring important blood-vessels, nerves, and viscera, they are also dangerous inasmuch as they frequently give rise to very extensive inflammation. It is not uncommon to see formidable collections of matter follow wounds of this description, especially, when the instrument with which they have been made, has penetrated any aponeurosis, or fascia. Stabs, and all other punctures, are not simple divisions of the fibres of the body, they are attended with more or less contusion and laceration. Hence, there is not the same readiness to unite, which we observe in wounds made with sharp cutting instruments, and, when ligamentous expansions are among the objects of injury, both the structure of the wounded parts, and the nature of the wound itself, often produce a train of severe local and constitutional symptoms. When an artery of consequence is punctured, the hemorrhage must be suppressed, either by exposing the vessel and tying it, or by applying graduated compresses and a bandage. The choice of these means must be determined by considerations, already hinted at in a preceding chapter. Immense agitation of the nervous system very often follows the infliction of a punctured wound, and this has been attributed to the injury of tendons, or nerves. This doctrine is now almost quite exploded, as surgeons so frequently see nerves and tendons wounded, without the occurrence of great constitutional disorder, in five cases out of a hundred. The explanation of the fact, that great derangement of the system is very apt to follow punctured wounds, is not yet unfolded in a satisfactory manner; but, the fact itself is fully established

by the surgical records of all ages, and on the firm basis of daily experience.

Punctured wounds are frequently very difficult and tardy of cure, on account of their being attended with the formation of deeply-seated abcesses and sinuses. The narrowness of their orifices also renders the extraction of any extraneous bodies by no means easy of accomplishment,

TREATMENT OF PUNCTURED WOUNDS,

In this part of practice, erroneous suppositions have very commonly led to very serious abuses. The unlimited idea, that the severe consequences of most punctured wounds are in a great measure owing to the narrowness of their orifices, induced numerous surgeons to practise, indiscriminately, deep and extensive incisions, for the purpose of rendering their external communication considerably wider. To have constantly in view the conversion of such injuries into simple incised wounds, was always a maxim, strongly insisted upon, and set forth as the reason of the above method of treatment. The doctrine even occasioned the frequent dilatation of punctured wounds by the still more absurd and cruel employment of tents.

Certainly, if the notion were true, that an important punctured wound, such as the stab of a bayonet, is actually changed into a wound, partaking of the mild nature of an incision, by the mere enlargement of its orifice, the corresponding practice would be highly commendable, however painful it might be. But the fact is otherwise; the rough violence done to the fibres of the body by the generality of stabs, is little likely to be suddenly removed by an enlargement of the wound. Nor can the distance, to which a punctured wound frequently penetrates, and the number and nature of the parts injured by it, be at all altered by such a proceeding. These, which are the grand causes of the collections of matter, which often take place in the cases under consideration, must exist, whether the mouth and canal of the wound be enlarged or not. The time, when incisions are proper, is when there are foreign bodies to be removed, abscesses to be opened, or sinuses to be divided. To make painful incisions sooner, than they can answer any end, is both injudicious and hurtful. They are sometimes rendered quite unnecessary by the union of the wound throughout its whole extent, without the least suppuration.

It is true, that making a free incision, in the early stage of these cases, seems a reasonable method of preventing the for