Closure Techniques For Wound Sutures

at one angle of the wound, ties a knot with three turns, CLOSURE OF THE WOUND 23 and with a continuous suture closes this structure through the length of the wound, keeping in mind that it is the most important resisting structure of the wall. This suture is ended with a three-tie knot. The continuous suture is ob- jected to by many for the reasons (r) that if infection occurs it will follow the suture through the entire wound; (2) that if any portion of the suture is injured or broken the structures separate its entire length. Considering these objections valid, for a time I discontinued this method of suturing and substituted the interrupted suture, but when infection oc- curred the catgut was slow in being absorbed or in disin- tegrating, and had to be fished out before the wound would heal, and it is much easier to catch one suture than many. The suture properly secured is unlikely to break, and where ordinary precautions are preserved the instances in which such sutures are infected or break are infrequent. The many knots incident to closure by interrupted sutures are a great source of danger. In thick and fat abdominal walls it is better that the fatty or superficial fascia should be united with sutures, as the procedure obliterates dead “space in which blood or liquefied fat may serve as a nidus for infection and cause discomfort as well as danger to the future welfare of the patient. These sutures should be interrupted and of plain catgut. Finally, with a No. o chromic catgut suture the skin edges are brought together by a continuous suture. The precaution should be exercised that strong traction is‘not made on this suture, as the skin is strangulated and may cause infection or even slough. 24 CARE OF GYNECOLOGIC PATIENTS DRAINAGE The question of drainage is not so momentous a one as it was twenty years ago, and the cases in which it is considered necessary are comparatively infrequent. The dependent position of the pelvis makes the vagina the choice outlet for drainage in woman. Drainage through this canal has the additional advantage of not weakening the abdominal wall, so that danger of hernia is decreased. The retro-uterine in- cision into the vagina ensures the lowest part of the ab- dominal cavity being the seat of the drain, and is conse- quently most effective. A vent in this situation affords a further advantage, that in extensive adhesions, or where the peritoneum of the pelvis has been much injured in the opera- tion, or by previous inflammation the contact of the intes- tinal coils with such raw surfaces can be prevented by pack- ing the pelvis with iodoform gauze. One end of the gauze pack is carried into the vagina and is withdrawn through: it when its purpose has been served. The best drain is the split rubber tube, which should be secured to the vaginal in- cision. Even where the pelvis is packed with gauze, espe- cially where-drainage is desired, the gauze should be supple- mented by the employment of. split rubber tubes. The gauze alone soon becomes clogged with exudate and serves as a tampon. rather than a drain. The vaginal drain, with the patient in a semisitting position, favors the most effective drainage of the peritoneal cavity. The cases are now rare when drainage through the abdominal walls has to be con- sidered for pelvic conditions. In appendiceal abscess and DRESSINGS 25 inflammation in the upper abdomen it would not, of course, be considered wise to afford escape through the vagina. In general peritonitis it may be desirable to have several open- ings for the escape of the infectious material, for it should not be overlooked that the tendency is for the drain to be walled off as a foreign body, and its area of action conse- quently becomes very much diminished. The action of the drain is greatly promoted by placing the patient in a semi- sitting position with the employment of a continuous instilla- tion of water by the rectum, known as the Murphy drip. DRESSINGS The treatment of wounds has been of late years much simplified, and it is recognized that nature will do her work well when the wound is properly protected. Care has been exercised during the operation to protect the wound surfaces from contact with infectious material, and when, as in in- flammatory conditions, it has been impossible to prevent such contact, it is a good plan after closing the peritoneum with a continuous suture to paint the wound with a 3.5 per cent. solution of iodin and dry the surface before closing it. Collections of blood in the wound are.prevented by ligation of bleeding vessels and the method of suturing. With the completion of the skin suturing, the wound and surrounding skin surface are sponged with a so per cent. solution of alco- hol, and the edge of the wound painted with a 3.5 per cent. iodin solution, after which it is covered with sterilized fluff gauze and a sterile gauze and non-absorbent cotton pad is 26 CARE OF GYNECOLOGIC PATIENTS held in place by strips of plaster or, better, by pieces of tape which are secured to plaster on either side of the abdomen and tied across the dressing. The latter method is prefer- able, as it affords easy access to the wound without the dis- comfort incident to pulling off the plaster, or the accumu- lation of a large quantity of the latter when it is cut at the side of the pad and new pieces covered over the cut ends. In addition to being neater in appearance and more com- fortable, it has the advantage of being economic, which is a matter of importance in the work of a large hospital. The dressing is completed by the application of a well-adjusted abdominal binder, which is pinned over the: covered wound. This bandage not only keeps the dressing in contact with the wound, but affords comfort and support to the patient in change of position. CLINIC WORK In the clinic of a large hospital, where the cases follow each other in rapid succession, it is important that each person be so drilled that he or she will understand what is expected at each successive step and be ready to discharge the duties promptly and without confusion. Supplies of dressings, sterile gowns, gloves, and other accessories should be accessible, but should not be uncovered and exposed in a room which is occupied by a number of attendants and ob- servers. After each operation the table covering should be changed and the operator and assistants change their gowns and gloves. Where a number of operations are done on the same patient, especially when plastic operations are done CARE OF THE PATIENT DURING THE OPERATION 27 about the vulva and vagina, not only the operator and in- tern but also the nurses should change their gloves before proceeding to the abdominal section, for it stands to reason the handling of the needles and instruments by the operator and nurses will necessarily lead to the soiling of the gloves of the nurses, when to handle sutures and ligatures with these soiled gloves for the subsequent abdominal operation would be prejudicial to the good healing of the wound, even did no more serious result follow. All soiled pieces of gauze should be removed from the room before beginning opera- tion upon another patient and the vestiges of blood should be mopped up. While there may be no danger to the suc- ceeding patient from the blood on the floor of a former one, it is unseemly that an operating room should have the. appear- ance of a shambles. As the gauze used in the. operation must be accounted for, it is evident that it is unwise to have the count confused by some left from a former operation. Perfect order, surgical cleanliness, and conscientious con- sideration of the interests of the patients should characterize the course of all the participants of a clinic, whether the in- dividuals treated therein be rich or poor. CARE OF THE PATIENT DURING THE OPERATION The room in which the operation is done should be ap- propriate for the purpose, well lighted and heated. The patient should be protected from drafts, and the abdominal viscera when the cavity is opened should be packed back with gauze. In a protracted operation the gauze or covering 28 CARE OF GYNECOLOGIC PATIENTS should be moistened with warm salt solution, and this satura- tion should be repeated from time to time, so that there will be no opportunity for the surface to become dried or chilled * from the continued exposure. The moistening of gauze packs which have been in place for some time will save the intestinal endothelium from injury. The anesthetist keeps the patient’s pulse, temperature, blood-pressure, and general appearance under observation, and is prepared to institute restorative measures whenever they seem to be indicated. It is important that the danger-line should be anticipated rather than to institute restorative measures only when the patient is beginning to succumb. Strychnin, ergone or some aseptic ergot, and atropin should be at hand for use hypodermically, and in all cases where a serious condition is possible, apparatus and material for hypodermoclysis or intravenous injection should be ready. In operations on patients who are previously much enfeebled by disease, or where the operation is likely to be greatly prolonged, the condition of the patient may be favorably maintained by em- ploying continuous hypodermoclysis during the operation. A needle beneath each breast, or inserted through the chest muscle. into each axilla, connected by a Y-tube with a saline reservoir, may, under the care of a nurse and watched by the anesthetist, be stopped temporarily or allowed to continue according to the exigencies of the case. Should the vitality flag in spite. of these measures, or in cases where they have not been instituted, resort should be had to intravenous injection of a saline solution, using a 1 per cent. solution of either sodium AFTER-CARE 29 chlorid or sodium citrate, to which may be added 1 dram of adrenal chlorid or 5 grains of caffein citrate. This procedure may be employed while the operation progresses, and 3 pint to I quart of the solution thrown in. In patients suffering from shock the amount of anesthetic should be kept at a minimum, and it is better that the patient should feel the procedure, and thus through stimulation of her nerve-centers promote reac- tion. AFTER-CARE The bandage having been applied to maintain the dressing in place, the patient should be covered with blankets and pro- tected from exposure while being transported to her room. When much shocked, artificial heat should be maintained by a hot blanket, and have hot-water bottles placed about her and be kept covered. Common sense should be exercised in the use of these measures, not because the patient has undergone an operation, but because they are needed. I have seen pa- tients on the hottest days in summer subjected to the applica- tion of hot-water bottles and other methods of maintaining heat, when heat abstraction was indicated. A patient with a pulse of good volume and bathed with perspiration calls for reduction of covering and withdrawal of artificial heat rather than its application. When heat is maintained by the appli- cation of hot-water bags and bottles, they should be watched, that the restless patient does not displace the blanket and come in contact with the hot-water receptacle. Such applications should never be made without the bag or vessel having been wrapped, or at least placed external to a blanket. The nurse 30° CARE OF GYNECOLOGIC PATIENTS should know just where each one of them is, and should inves- tigate from time to time to see they have not been displaced. It must be understood that the resistance of a patient in shock is much reduced, so that she would be burned from an exposure that otherwise would not affect her. Should a burn occur, the nurse should not attempt to conceal it from the physician, however willing the patient may be to co-operate in the decep- tion. Be sure it will come to his knowledge some time, and he will thereafter fail to have any confidence in the nurse. The patient in bed, the room should be darkened, and ventilation afforded without placing her in a draft. The members of the family and all others than the necessary attendants should be requested to leave the room. Even when the patient is sleep- ing, with pulse and breathing good, she should not be left with- out skilled attention, for without warning she may have an attack of vomiting, and if without skilled attention may by inspiration draw the vomitus into the trachea, to cause a sub- sequent attack of pneumonia. The nurse keeps a record sheet on which she should register, in severe cases at least every four hours, the temperature, pulse, respiration, and any symptoms which may have a practical bearing on the subsequent course of the convalescence. The continuous retention of one position becomes extremely irksome to a patient who has been unaccus- tomed to lying in bed, and the nurse should study to make this imprisonment as endurable as possible. Much may be done for her comfort and distraction by frequently changing her position, placing a pillow beneath the limbs or under a shoul- der, turning her on one side, and placing the limbs semiflexed AFTER-CARE 31 with a pillow between the knees, or the under limb extended while the upper one is flexed and rests on a pillow. Bathing the face, shaking up the pillow beneath the head, holding her hand, and in general showing that the nurse has sympathy for her charge and is anxious to alleviate her discomfort, has a wonderful effect in making her satisfied with the situation. Never let the patient be uncomfortable when her distress can be obviated. In some hospitals there seems to be a feeling that the patient should not have anything under her head for some hours after the operation, but this is like many other miscon- ceptions. The patient may at once have a pillow unless she has lost so much blood as to render it desirable to keep the head low in order that the blood can enter it without increased car- diac effort. In ordinary cases to make the patient go without a pillow is an unnecessary punishment. The patient will not infrequently ask for water and more often for broken ice. The latter should be withheld, for its administration leads to dry- ness and cracking of the lips and tongue, when her condition is truly uncomfortable. It is better that the patient should be given hot water by the tablespoonful, and if this is well-borne and unattended by nausea or vomiting, she can have a cup of weak tea, quite hot, without milk and with but little sugar. The nurse not only watches the heart action, the respira- tion, and the condition of the skin, but later the performance of other functions, as evacuation of gas by bowel and the desire to pass urine. As the bowels have been freely evacuated, the patient has taken but little water prior to the operation, and her skin has possibly acted freely during and after it, the secre-