A New Suture-Fastener for Silver Wire, especially adapted for Operations upon the Cervix and Perinaeum. BY AUGUSTIN H. GOELET,"m. D., NBW YORK. REPRINTED FROM ffitje Neto Yorfc jfttetocal for May 26, 188S. Reprinted from the New York Medical Journal for May 26, 1888. A NEW SUTURE-FASTENER FOR SILVER WIRE, ESPECIALLY ADAPTED FOR OPERATIONS UPON THE CERVIX AND PERINEUM * By AUGUSTIN H. GOELET, M. D., NEW YORK. Those who have operated much for lacerated cervix, using the silver wire for suture, have experienced the great objection to its cutting into the tissues when twisted. If twisted tight enough for thorough coaptation, it is sure to cut deeply, and will be found buried out of sight when the sutures are removed. Sloughing or non-union is often the result, as the suture becomes loosened when the tissues give way, and this allows the margin of the wound to gape. The furrows left by the twisted sutures may be seen on the cervix years after the operation. But silver wire has held the preference over all other sutures for this location, be- cause those which require tying are inconvenient of applica- tion. The catgut does not last, except for supplementary sutures, and silk is more apt to cut than silver wire. Anything which will avoid the necessity of twisting the silver wire will, I feel sure, be appreciated. For this pur- * Read before the Section in Obstetrics and Gynaecology of the New York Academy of Medicine, April 26, 1888, 2 A NEW SUTURE-FASTENER FOR SILVER WIRE. pose I have devised this lead button-shield, which, when the wire has been well shouldered, is pushed down upon it tightly against the cervix, and clamped like a shot. (See Fig. 1.) It has a smooth concave surface, with rounded edges, which may be molded to fit the side of any cervix, and from the middle of the outer or convex surface there is a pro- jection resembling an oblong shot, through which there is a perforation for the wire. The wire should be well shoul- dered, either with the knot-tyer or the needle-holder, which has had a shallow groove made across the end to keep the Fig. 1. Fig. 2. wire from slipping off. When the knot-tyer is used, the ends of the wire must be crossed, which need not be done when the needle-holder is used. The shield may be clamped in position by the ordinary strong needle-forceps, and a multiplicity of instruments avoided. Usually two sutures, fastened in this way on each side of the cervix, are all that are necessary, even in very exten- A NEW SUTURE-FASTENER FOR SILVER WIRE. 3 sive lacerations, with an additional catgut suture on each side, near the os. There is the same objection to silver wire when it is used for closing the external perineal wound. Although the skin is more able to resist than the mucous surface, great care is always necessary to avoid twisting the suture too tight, and, as an extra precaution, it is loosened after- ward. When the tissues become swollen, it will cut some even then. I have prevented this cutting and secured better results by using the same fastener as described above, with the ends of the shield surface turned up as shown in Fig. 2, to avoid digging into the flesh when the knees are brought together. When silver wire is used for closing the abdominal wound after laparotomy the same fastener may be used with advantage if the shield surface is flattened out somewhat. As a substitute for the lead button used to fasten deep sustaining sutures in large flap-operations where there is much strain on the line of union, I have had the shield sur- face made larger and curved up at the sides (something like a small Bozeman button), and the projection and perfora- tion in the center, which avoids the necessity of using shot. (See Fig. 3.) The advantages claimed for this fastener over the twisted suture are, viz.: 1. The rapidity of its application. 2. The support to the parts furnished by the concavity of the shield surface. 3. The wire will not cut and allow the sutures to loosen and the margins to gape. 4. The sutures are more easily removed because the wire will not be buried out of sight. 5. Fewer sutures are required. 6. It promotes more prompt union and better results. 4 A NEW SUTURE-FASTENER FOR SILVER WIRE. To remove these sutures the projection is seized with a pair of dressing forceps, slight traction made, and the scis- sors inserted under the shielding surface, and one side of the wire cut. Fig. 3. Fig. 4. These buttons have been made for me very nicely by Mr. Philip II. Schmidt, the instrument-maker. From the discussion which followed the reading of this paper, I fear I did not make one point quite clear and may be misunderstood; therefore I will add another illustration (Fig. 4) to show the position of the button-shield when in place. They are applied across the line of union of the two denuded surfaces on each side of the cervix, the concavity of the shield fitting the convexity of the side of the cervix, and when pushed down in place, while the projection is in the grasp of a pair of strong needle forceps, it is compressed like a shot, and the ends of the wire cut off close to the lead projection. The claims of advantage for this fastener, as set forth above, have certainly not been exaggerated. I have used it A NEW SiTTURE-FASTENER FOR SILVER WIRE. 5 as well as the twisted suture long enough to be sure that it is a decided improvement over the twisted suture, although it may not be (as was claimed by some present) an actual necessity. It might likewise be claimed that the electric light and telephone are not actual necessities; still this is no argument that they are not decided improvements upon gas and the telegraph. I assert that the silver wire when twisted will cut more or less when the tissues become swollen, as they do after these operations, and that the use of this shield will prevent it. Let him who doubts the truth of this assertion try it for himself. 243 West Fifty-fourth Street. © G REASONS WHY Physicians Should Subscribe .-^s A T -V' FOR The New York Medical Journal, Edited by FRANK P. FOSTER, M. D., Published by D. APPLETON & CO., 1, 3, & 5 Bond St. 1. BECAUSE : It is the LEADING JOURNAL of America, and contains more reading-matter than any other journal of its class. 2. BECAUSE : It is the exponent of the most advanced scientific medical thought. 3. BECAUSE : Its contributors are among the most learned medical men of this country. 4. BECAUSE : Its "Original Articles" are the results of scientific observation and research, and are of infinite practical value to the general practitioner. 5. 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