Wounds are closed by strapping, by elastic bands, or sutures.

A. Wound-Closing By Means Of Strapping

Co-aptation of the margins of the wound by means of bands of adhesive plaster may be carried out so long as spontaneous cicatrisation has not commenced and the skin moves easily over the deeper parts. It causes no pain to the patient and demands neither local nor general anesthesia. Strapping of American make and good quality is used, four or five centimetres wide, twenty to twenty-five centimetres long. The strips must be long enough to get a firm grip on the skin. As it is not sterile, we must carefully avoid bringing the surface of the strapping into actual contact with the raw surface of a wound, and the line of union is protected by a slip of paper, or of celluloid, sterilised.

The skin adjoining the wound is shaved, thoroughly dried, then the lips of the wound are brought together and maintained exactly in correct position by several bands of strapping applied perpendicularly to the direction of the wound (Fig. 89). At the end of a week the strapping is removed, and the wound found to be united.

B. Wound-Closing By Elastic Traction

When extensive loss of substance exists and the lips of the wound cannot be brought into apposition, recourse is had to elastic traction. This method is also used for covering stumps.

FiG. 89.   Bringing together the lips of a wound by means of strips of adhesive plaster.

FiG. 89. - Bringing together the lips of a wound by means of strips of adhesive plaster.

Fig. 90.   Bringing together the lips of a wound by means of elastic traction.

Fig. 90. - Bringing together the lips of a wound by means of elastic traction.

The bringing together of the edges of a wound by elastic traction is carried out in the following manner. Strips of adhesive plaster seven or eight centimetres wide (about three inches), and exceeding in length by-ten centimetres (four inches) the length of the wound, are provided on one edge with boot-lace hooks, by-means of the punch in use by shoemakers. On either side of the wound and parallel to it, a piece of strapping bearing the boot-lace hooks is made to adhere firmly to the skin (Fig. 90). The hooks of the two strips are brought towards each other by means of a lacing of strong rubber, the tension of which is regulated to a suitable degree.

The margins of the wound are brought together progressively under the influence of the elasticity of the rubber. When there has been no loss of cutaneous substance, or when the loss is but slight, the raw surface may be covered in forty-eight hours. When the loss of substance is more considerable, still this procedure allows of the area of the wound being diminished to a very large extent.

A similar method is used to unite the edges of flaps on stumps. It is admitted that, amputations being nearly always practised on an infected limb, the stump cannot be sutured. To check the retraction of the soft parts of stumps left open, we may make use of the method established long ago by American surgeons, that is to say, continuous traction on the skin. Two strips of adhesive plaster of suitable dimensions are applied at opposed points on the surface of the limb, and meet on a small piece of wood1 to which traction cords are attached. A weight of about a kilogram and a half (about 3 lbs. English) is sufficient to oppose the retraction of the soft parts. This traction in no way interferes with the dressing of the wound. When sterilisation is complete it is easy to suture the flaps which are now in the same position as though the amputation had just been performed.

1 "Stirrup-piece" (Trans.).

C. Wound-Closing By Suture

Secondary suture of wounds should always be done under anaesthesia. If the skin is adherent to the deeper parts, it must be dissected up to a sufficient extent. To refresh the edges it is enough to remove the epithelial margin by an incision in the healthy skin a millimetre beyond its external border. The simple excision of the epithelial margin will suffice. There is no need to curette the granulating surface. The integuments are dissected up for a distance sufficient to ensure good adjustment of the edges. Usually, the deep parts come together spontaneously. In cases where it may be of service, deep suturing may be practised, especially sutures of aponeuroses. The closure is usually done without drainage, because the bacteriological examination has demonstrated that microbes are no longer existent in the wound.

D. Suture Of Muscles And Nerves

Suturing of muscles and tendons is carried out as early as possible, in order to avoid retraction. It is the same with nerve suture. Directly the wound is sterile, the operative conditions become the same as in aseptic surgery.

E. Closure Of Wounds Of Compound Fractures Or Joint-Injuries

In the majority of cases it is possible to close a compound fracture or a wounded joint in the same way as a wound of the soft parts. Even in bad smashes of the limbs, if the closing follows the traumatism by a few days, the osteoperiosteal sac which bounds the seat of the fracture has supple walls, which a compressive dressing will so far bring together as to efface the cavity. In these cases suture may be practised without troubling as to the loss of bony substance. However, in certain fresh epiphyseal fractures, and in the majority of old fractures, the osseous cavity has rigid walls, so that it is necessary to fill it up. We have obtained good results with Mosetig's and Beck's pastes {la masse de Mosetig et la pate de Beck, Fr.). But better results have been observed by MM. Guillot and Woimant as a result of the employment of adipose grafts, the success of which is almost invariable. The inert substances which are used for filling cavities offer this disadvantage-they necessitate a musculo-aponeurotic wall to isolate them from the cutaneous sutures. They have to be worked up and softened by heat; and they yield practically 50 per cent. of failures. Adipose grafts, on the other hand, may be closed in under a simple cutaneous suture. They may, in the event of an extensive abrasion of the soft parts, form part of a cutaneous strip pressed into service from the neighbouring parts. Lastly, the surgeon can always find them ready to hand on the person of the patient himself.

Wounds of joints are closed in the same way. Should one of the bony extremities contain a large cavity, it is filled up in the manner we have just pointed out, before proceeding to the closure of the articulation already indicated.