He lived just one week after going there and his wife had to borrow money enough to go and claim his body from the undertaker, and after being put to enormous expense for a metallic coffin and complying with the various regulations, she started back with the body. In Iowa the train was derailed and wrecked, injuring the child so it died within a week and causing serious injuries to the mother; a family wiped out, while a medical "forflusher" skinned them out of $50 for alleged scientific advice.

Sometimes when I think of some of these things that have passed like a panorama before my life, my mind reverts back to the old bible text: "What shall it profit a man, if he shall gain the whole world, and lose his own soul?'' (To be continued.)

THE APPLICATION OF CERTAIN PRINCIPLES OF PLASTIC SURGERY IN CLOSING DEFICIENCIES IN EXPOSED CUTANEOUS

SURFACES

By Charles C. Miller, M. D., 70 State Street, Chicago, Ill.

(Continued from Page 45 February Recorder)

In this work I shall make no effort to detail all the many plans which can be followed by an operator in approximating various forms of deficiencies, but outline some of the methods of procedure with which all should be acquainted.

In closing defects, such a wide variation exists in the different lesions that innumerable modifications of the many plans described, may be practiced, and the teacher should not burden the student of the subject with set methods so that his individual judgment is hampered and discouraged.

Defects in the tissues should always be closed without tension and for this

reason the method first outlined of immediate adduction has a decidedly limited scope in comparison to the methods. where tissues are freely undermined.

The surgeon should appreciate the proper method of undermining tissues, and when working upon the body in attempting to close a very large defect is less likely to err in the undermining of the tissues than is the surgeon who is undermining to close a comparatively small defect of the face, yet it is even more important that the latter, moreso than the former, undermine properly. Where the fascia beneath the skin is ill defined the dissection should extend through the fatty and areoler tissue and more or less of a layer of these latter tissues must be included in the elevated portions.

The knife may be used in undermining though in many cases scissors are used to a better advantage, and in a much larger percentage of cases it will be best to use a blunt dissector where circumstances permit. The blunt dissector seeks lines of least resistance, and while there is a laceration of the tissues which is not entirely desirable, if proper aseptic and antiseptic precautions are taken the healing is in all respects satisfactory.

Where vessels are torn through by the blunt dissection their closure is more perfect, and as a result much less bleeding occurs than in those cases where the sharp edge of the scalpel is used in elevating the tissues. If possible the undermining is accomplished so as to permit of access to the undermined tissues, and whenever it is possible to gain direct access to an opened vessel, torsion may be used to an advantage in closing it.

Some surgeons never learn to apply torsion properly in closing an open vessel. This is the result of carelessness and haste and every surgeon should practice this method of closing small vessels if he hopes to perform the various operations about the face to the best advantage. The vascularity of the tis

sues is such that the operator may be much annoyed and inconvenienced by bleeding from small vessels and it is not practical to apply numerous fine ligatures.

Undermining should always be continued until an easy approximation of the tissues is secured in the absence of particular contra-indications to limit the extent of undermining. It must be remembered that an undermined flap may draw upon and distort a rather distant point, and in some instances it is highly important to prevent even moderate traction upon certain parts. As an illustration of this, attention is called to the face not to inadvertently distort some wounds of the face in such a way as to draw upon the eyelid and produce, subsequently an unsightly and most annoying ectropium. The greatest care should always be taken by the operator in closing a deficiency in the soft parts of the face not to inadvertently distort some portion of the face. The operator should also remember that such distortion may not make itself apparent at the time of the operation, but that a gradual development of such distortion. may be expected to manifest itself as the result of moderate constant traction.

The great vascularity of the tissues of the face sometimes proves annoying to the surgeon after he has undermined an area. Where many small vessels are bleeding the hemorrhage may be of such a nature as not to permit of its control by the securing of individual vessels. In such a case as this the operator finds that he can control the bleeding by packing with strips of gauze saturated in a one to seven thousand solution of the active principle of the suprarenal gland. This solution controls the bleeding temporarily by contracting the vessels and the parts may be closed and moderate pressure applied to prevent secondary hemorrhage after the effect of the suprarenal solution his disappeared. It is well to pass a suture for closing one

angle of the wound when the suprarenal solution has been used and to leave it untied for several hours so that if blood accumulates beneath the skin it may be gently washed out with a warm sterile solution. It is well to be somewhat careful in the use of the suprarenal solutions, and to use as I have recommended, the weaker solutions of this drug so that too much contraction is not secured, as the nutrition of the tissues may be endangered where a one to one thousand solution is used.

In suturing the tissues of the face after undermining it is not highly important as to the suture material used or as to the manner of suturing. The flaps should fall together without resistance and as they are held without tension, the sutures merely immobilize. A subcutaneous catgut suture can be used. Then the operator is certain there will be no stitch marks to mar the result, but it is rather difficult to secure a perfect approximation in some cases with a subcutaneous gut suture and there is always a danger of the fine gut giving way too soon and allowing separation of the wound margins. A continuous silk, horse-hair or very fine silk worm gut suture permits of a very close approximation of the skin, and where carefully placed so that there is no tension very little likelihood exists of noticeable stitch marks subsequently. A silk worm gut stitch which has been described as the herring bone stitch may be used for approximating the parts and carefully applied the approximation is excellent. This stitch is buried and is removed when the parts have firmly united.

After the parts are carefully sutured. adhesive strips may be used to insure approximation of the superficial parts without tension upon the skin.

Where a deficiency has been closed. about the cheeks or jaw adhesive strips alone should not be trusted for immobilization, but a bandage should be applied to further insure this. The pa