BARBED WIRE CUTS 487 



patch is torn loose, while at other times the whole pectoral 

 region is rent of its cutaneous covering which hangs down 

 like an apron. 



TREATMENT. — In this var.iety painstaking repair of 

 the breach is the only sensible course to pursue. Although 

 some part of the great skin-flap will surely prove to be un- 

 viable, it is nevertheless prudent to preserve it intact until 

 the unviable zones are distinguishable by the formation of 

 lines of demarcation some days later. 



The ; operation begins with a patient shaving of the cir- 

 cumference of the wound and the circumference of the flap 

 so as to make a hairless tract for the sutures no less than 

 three inches wide. In addition the flap should be shaved in 

 spots here and there, to serve as entrance points for the 

 "quilting sutures" to be applied subsequently. 



The general plan of procedure, after the field has been 

 mechanically and medicinally disinfected with unmistakable 

 thoroughness, is to (i) "quilt" the patch to the body from 

 the attached part toward the free end, by means of a series 

 of simple stitches systematically arranged over its surface ; 

 (2) to hold the edges together with button sutures one inch 

 apart and approximate them neatly with interrupted su- 

 tures; and (3) to provide numerous drainage orifices to pre- 

 vent the accumulation of subdermal serosity. 



The quilting sutures should be as short as possible in or- 

 der to incarcerate as little skin as possible, and they should 

 always be inserted before the edges are sutured together 

 because a short stitch cannot be applied, even with a small, 

 full curved needle, after the patch is once attached to the 

 body. 



The sutures are covered with a thick layer of collodion 

 and the drainage orifices are kept open by wadding them for 

 a few days with gauze plugs which are renewed frequently. 



If fluctuant areas appear which cannot be drained 

 through the orifices previously provided, they are lanced. 



At the end of eight days the sutures that are no longer 

 of service, either on account of primary union or stitch ne- 

 crosis, are taken out, the buttons are removed and the dead 

 areas resected. The latter, however, should not be molest- 

 ed if still serviceable in holding viable parts in place. The 

 quilting sutures are the last to be removed. 



Compared with the practice of hurriedly sacrificing the 

 skin flap in these cases where successful repair seems im- 

 possible the above procedure is always attended with much 

 better final results, as some of the skin, and sometimes all 



