Journal of the American Medical Association (JAMA)
method of securing its ends, is again described and illustrated. Quoting from the first of these, I said : It occasionally happens . . . that the different layers of tissue passed through in the course of the operation must be sutured separately in order to insure a good result. Here catgut will not answer, for the reason that it is dissolved or, at all events, weakened, before it' has answered its purpose, and the sutured layers separate widely in spite of every care. To meet the require¬
... t the require¬ ments of these cases I have devised a suture which, while it serves all the purposes of a deeply buried layer suture, at the same time can be removed. I have called this the "crossed suture." Silkworm gut or sill; may be used for this purpose, but the former is preferable. Both ends of the thread are threaded with needles of the proper curve, and both are passed beneath the lowermost or the deepest layer to be sutured, at sufficient distance from the edge to obtain a good hold thereon. As the thread is drawn through either edge of the layer, the loop is drawn taut beneath. The thread is now crossed, the needle which passed the latter through the outer edge crossing over the inner edge, and that which passed the thread through the' inner edge going to the outer. The needles are now passed through the next layer as before, from below upward, securing a firm hold as in the first layer. The threads are again drawn taut and crossed as before, each time of crossing securing a layer until the surface is reached, the last layer, of course, being formed by the skin itself. While Dr. Canac-Marquis concludes his operation by the use of "a lead nickel-plated shield threaded and shotted," I have for some years attained the same result in a slightly different manner. Quoting from my book, "A Treatise on Appendicitis," 1900: The crossed sutures are tied in pairs on either side of the wound. In order to guard against cutting of the skin from the silkworm gut. the sutures are tied over "bolsters" of sterile gauze or, what I find exceedingly convenient for this purpose, sections of thickwalled tubing of soft rubber (aspirator tubing) are used, the silk¬ worm gut being passed through the lumen of the tubing. This method gives all the advantages of buried layer sutures, and yet places completely within control the length of time the sutures are to remain in place. . . Removal is accomplished by cut¬ ting the suture beneath the bolster on one side, and making traction on the other end of the thread. While my first article was in the hands of the printer, and after I had employed the method of thus placing a removable layer suture in practically all the situations in which it is applicable, Well's translation of the first edition of Pozzi's work on gynecology appeared. I then became aAvare, for the first time, through a very scant reference to the matter by Pozzi (Vol. II, pp. 980, 981), that a similar suture had been described by Heppner for the perineum. Taking up, next, Dr. Canac-Marquis' "Technic of Herniotomy for Radical Cure of Hernia": Bryant, as 'far back as 1889, advocated the use of the hernia! sac itself to form a pad of resistance to intra-abdominal pressure. In the "Transactions of the New York State Medical Association," 1889, under the heading "Treatment of Hernia," Dr. Bryant says: I can not close this portion of the subject without calling to your attention a somewhat newer method of operating that I have practised on three distinct occasions. It certainly has some features that commend it. It is performed by weaving the sac, after its separation and its neck has been tied with catgut, into the pillars of the ring. He then illustrates slits through which the sac is woven back and forth, "and finally the whole mass is quilted with deep stitches of catgut." Though the details of Bryant's old operation, since aban¬ doned, differs somewhat from your correspondent's, still the fundamental principle involved remains the same, and, "honor Avhere honor is due." In regard to Dr. Canac-Marquis' "New Modification of Alex¬ ander's Operation for . Shortening the Round Ligaments," 1 would recall to your attention the fact that in the "Annals of Surgery," 1896, occurs a paper by Robert Abbe, entitled "Fixation of Round Ligaments in Alexander's Operation." After referring to a previous method of his OAvn, Abbe says: The idea occurred to me of utilizing the round ligament itself for the double purpose of sewing up the inguinal canal and securing the ligament immovably. This, I found, was easily accomplished when the ligament was drawn out four inches, as was always readily done.The ligament was drawn on until the uterus was firmly held well forward. The needle and loop now drew the ligament through new punctures on either side of the canal, crossing it to become a continuous suture for the canal. Three such stitches completely closed the canal up to the spine of the pubis, and left more than an inch and a half of ligament over. This was turned back over the last portion of the wound and stitched to it by one fine catgut stitch. The use of living tissue as a suture thus serves the double pur¬ pose of fixing the uterus immovably and binding the canal per¬ manently. This is identical with your correspondent's method, except in the minor details of closing the superficial structures. Unless your contributor can substantiate his implied claim as the originator of these three points in technic by publica¬ tions bearing date earlier than 1889 in the case of the hernia operation, 1891 in the case of the removable layer or figure-ofeight suture, and 1896 in the case of the modified Alexander's operation, the credit of the method of weaving the pillars of the ring together by means of the sac itself should be given to Bryant, that of a removable suture to Heppner and myself, and that of employing the round ligament to close the inguinal canal and at the same time secure the uterus in position in Alexander's operation to Abbe.