Compliments of the Author. 
A CONTRIBUTION TO 
Plastic Surgery. 
BY 
WILLIAM B. VAN LENNEP, A.M., M.D., 
PHILADELPHIA. 
Reprinted from the Hahnemannian Monthly, October, 1893. Fig. 1. 
Fig. 2. 
Fig. 3 Fig. 4. 
Fig. 5. Fig. 6. 
Fig. 7. 
Fig. 8. Fig. 9. 
Fig. 10. A 
CONTRIBUTION TO PLASTIC SURGERY. 
BY 
WILLIAM B. VAN LENNEP, A.M., M.D., 
PHILADELPHIA. 
The subject of reconstructive or reparative surgery, as well as that 
of preservation so closely allied to it, has been particularly impressed 
upon my mind during the past year. For this reason, as has been 
my custom in the past, the annual meeting of the State Society seems 
an appropriate occasion to bring the subject up for discussion. 
In looking over my table of operations since the last meeting, I 
have selected, from quite a number, the following ten cases which 
may be taken as more or less typical of the work done on these lines : 
I.- Ficious union of ulna and radius ; contracture of flexor mus- 
cles ; osteotomy aud osteoclasis ; tendon lengthening ; cure: 
W. E., boy of 8 years, referred to me by Dr. C. G. Abbot, of 
Woodbury, N. J. He had sustained a fracture of both bones of the 
right forearm several months previously ; union had taken place at 
an obtuse angle, and there was an accompanying contracture of the 
flexor muscles of the forearm. The extent to which the fingers and 
wrist could be extended is shown in Fig. 1. Considerable callus 
could be felt between the bones, and, thinking the contraction might 
be due to adhesions, massage, and passive and active motion were 
given a thorough trial for three months, when operative interference 
was consented to and undertaken. 
The palmar surface of the forearm was incised from the annular 
ligament to above the seat of fracture; this latter was exposed in 
the radius, and the bone divided with the osteotome. The ulna was 
broken across the knee. The muscles were separated, and examined 
carefully down to the bones and interosseous membrane. No adhe- 
sions were found, and the contracture did not disappear after the 
deformity was corrected. Lengthening of the tendons was 2 
then undertaken, just above the wrist, according to the method 
of Anderson. 
The superficial and deep flexors of the fingers, the long flexor 
of the thumb, the flexors of the wrist, and the palmaris longus 
were successively lengthened, until the deformity was found to be 
completely overcome. The amount of lengthening necessary for 
this purpose varied from one to one and a half inches, approxi- 
mately. 
The wound was tamponaded with iodoform gauze, and dressed 
with sterile gauze. At the end of a week the tamponade was re- 
moved, the wound tightly closed with a buried suture of catgut 
without drainage, dusted with iodoform (one part) boric acid (three 
parts) corrosive sublimate (one to five hundred), dressed with sterile 
gauze, and put up in a starch cast. As usual, the strictest antiseptic 
precautions were taken throughout. 
At the end of two weeks the dressing was taken down, and the 
wound found healed, with the bones in good position. This was 
repeated twice a week for six weeks, passive motion, massage, and 
Faradism being given each time, when he was sent home from the 
Camden Homoeopathic Hospital for Women and Children, where he 
occupied a private room. The same treatment, without any splint, 
was kept up for two months longer, when the cure was complete. 
The result is perfect as regards function and the amount of exten- 
sion, as the hand lies easily on a flat surface, is shown in Fig. 2. The 
cicatrix is slightly adherent to the tendons, and moves with them 
somewhat. 
II.- Old, traumatic rupture of the membranous urethra ; complete 
occlusion of urethra ; urinary fistula in thigh ; urethroplasty ; cure: 
In 1884, the patient, while walking along a fence, fell astraddle 
of it, striking his perimeum. Only a few drops of bloody urine 
were passed, and, as the catheter could not be introduced, the blad- 
der was aspirated a number of times. A week later a large peri- 
neal abscess was opened. This was followed by recurring abscesses, 
and finally, a fistula through which all the urine was passed. In 1887, 
he entered one of the large Philadelphia hospitals, and was operated 
a number of times, but the fistula persisted, and soon all the urine 3 
was again discharged through the perinaeum. Abscess after abscess 
appeared, until he came under the care of Dr. A. F. Brandt, of 
Harrisburg, Pa., who sent him to me. 
Examination, November, 1892, showed the following condition: 
No instrument would go through the urethra, all being arrested 
in the bulb. In the median line of the perinaeum was the cicatrix 
of an external urethrotomy completely healed and soft. To the left 
of this was a mass of cicatricial tissue, which extended for some dis- 
tance down the inner side of the thigh, where there were a number 
of fistulous openings through which all the urine was passed. 
The patient was anaesthetized eleven times, to which might be 
added fifteen more previously, and a number of measures were un- 
dertaken, although each procedure does not represent a separate sit- 
ting or operation : 
1. Epicystotomy to divert the urine, with the introduction of a 
catheter-a-demeure (Skene-Goodman) through the suprapubic open- 
ing. This had to be changed from time to time as it became en- 
crusted with phosphates. The irritation it produced was combated 
by frequent irrigations, but it became so severe, finally, as to pre- 
clude sleep, while the straining brought on very troublesome haem- 
orrhoids. As soon as the catheter was removed the suprapubic fistula 
healed spontaneously, the urinary distress disappeared, and the haem- 
orrhoids ceased to trouble him. 
2. Perineal urethrotomy, by means of which were found the pos- 
terior end of the membranous urethra, well under the pubic arch, 
and the proximal end of the anterior urethra close to the edge of the 
scrotum. There was a gap between these ends of fully an inch and 
a half, and it was of course impossible to approximate and suture 
them. 
3. Excision of the mass of cicatricial tissue which filled the right 
half of the perinaeum and extended down the thigh, leaving a large 
raw cavity. 
4. Complete dissection and removal of the inner layer of the pre- 
puce (Wolff, Wblfler), which was transplanted as a graft (1J by | 
inch) to form the roof and sides of the new urethra. This took 
partly and failed partly, the result being a good roof but raw sides. 
5. The application of skin grafts after the method of Thiersch to 
the sides of the urethra. This was successful, every graft taking. 
6. Closure of the gap in the perinaeum and thigh by sliding and 
twisted flaps and Thiersch skin grafts. The flaps were obtained 
from the thigh and the side of the scrotum; the grafts were taken 
from the abdomen. 4 
7. Formation of the floor of the urethra by a reversed flap, pe- 
dunculated and twisted, the skin surface toward the urethra. This 
required two sittings, as the first attempt was a failure, and its raw 
surface was covered by sliding flaps and skin grafts (Thiersch and 
Reverdin). 
8. Internal urethrotomy, first with the Maisonneuve and then with 
the Otis dilating urethrotome, to divide a linear stricture on the roof 
of the urethra at the junction of the anterior end of the grafts 
with the mucous membrane. This stricture, being partial, has not 
recurred. 
9. Sounding under ether, then under cocaine, and finally without 
any anaesthetic, the patient at present taking without difficulty a No. 
38 (Charriere) curved, conical sound. 
30. Cauterization of three small fistulous openings which resulted 
from tension on one of the flaps, with the actual cautery, potassa 
fusa, and nitrate of silver stick, until the perinseum is now firmly 
and definitely healed. 
At present his condition is an interesting and instructive one: The 
urine is passed entirely per urethram and the stream is thrown with 
considerable force. Erections and nocturnal emissions occur with 
their previous normal frequency, and, while some semen is ejected, 
most of it remains in the urethra and has to be squeezed out. The 
loss of the compressor urethrae muscle-the voluntary as well as 
surgical sphincter of the bladder-is also shown by the fact that the 
calls to urinate must be answered promptly, and if they are neg- 
lected too long, the urine gushes out involuntarily. Strangely, this 
seems to be gradually decreasing. The capacity of the bladder has 
improved greatly since the suprapubic catheter was removed, and is 
now normal. He urinates three times during the day, on retiring 
and arising, and does not have to get up during the night. The 
contraction of the numerous scars on the right side of the perinseum 
has shown itself by drawing the urethra slightly in that direction, 
and this must be remembered in sounding. As might be expected, 
the mental condition shows a very marked change for the better. 
III.-Excision of dura mater; closure of the defect with trans- 
planted graft from the pericranium ; healing: 
I. G., set. 29, had been subject to epileptic seizures for a number 
of years. They began in the left lower extremity, spread to the 
upper, and then became general. Loss of consciousness was incon- 
stant. With intermissions of a few days he had these seizures several 
times daily, and they lasted from five to fifteen minutes. Their sup- 
posed origin was a traumatism. There was a scar over the left 5 
parietal eminence, in which region the sknll had been explored, and 
there was excessive tenderness and pain at a corresponding point on 
the other side of the head. A deep stricture had been cut through 
the perinseum, and a ring of haemorrhoids had been removed. He 
denied syphilis. 
Operation, at the Hahnemann Hospital, July, 1893. The scalp 
was laid back in a large semi-circular flap, and the trephine applied 
over the upper portion of the fissure of Rolando. In this region, 
and backward and toward the middle line, the skull presented a 
decided hyperaemic appearance, bleeding quite freely, in marked 
contrast with the surrounding normal bone. The trephine opening 
revealing nothing, the rongeur was used, working backward and 
toward the middle line, until quite a large aperture was made. 
About an inch posterior to the trephine opening and at the point of 
greatest external sensitiveness, the dura was intimately attached to 
the skull, much thickened, and apparently bony. The same condi- 
tion was found on its inner surface, from which there projected a 
good sized piece of bone. This portion of the dura was excised, 
leaving a gap one and a half by one inch in size. To prevent hernia, 
Keen's suggestion was followed: a piece of the pericranium was 
dissected off, trimmed down to fit the opening, into which it was 
stitched, with the osteogenic side outward. The scalp was closely 
sutured with fine, iron-dyed silk (buried), except at the most depen- 
dent portion, where a thin strip of iodoform gauze was inserted as a 
capillary drain. This was removed in forty-eight hours, and the 
wound healed throughout without reaction or suppuration. 
It is too early yet to speak of the result. There were several con- 
vulsions, and left-sided hemiplegia, immediately after the operation, 
but the latter has disappeared, and the former recur at long inter- 
vals. There is no tendency to hernia of the brain. 
IV.-Large floating spleen ; suspension in place until attached by 
the induction of plastic inflammation: 
Mrs. A. M., set. 35, had been the rounds of the Philadelphia 
hospitals for a pelvic tumor that had been variously diagnosed. I 
first saw her on the operating table, under ether, at the Camden 
Homoeopathic Hospital for Women and Children, when it was very 
easy to lift the tumor out of the pelvis, and recognize the spleen en- 
larged to about ten times its normal size. It could readily be moved 
to any part of the abdomen. From her history and subsequent in- 
spection I judged the enlargement was of malarial origin. The 
symptoms were those of pressure and traction on the pedicle. Exci- 
sion would have been very easy. 6 
The abdomen was opened in the middle line, the pedicle untwisted, 
and the organ pushed up into place. Another opening was made 
just below the border of the ribs, and suture to the abdominal wall 
attempted. The stitch tore out. A strand of heavy silk was passed 
with a needle into the abdomen, close to the spinal mass of muscles, 
as high up as possible, guided by the hand inside, and then out again 
in front. By throwing this loop around the spleen, drawing on it 
and tying the ends on the outside, the organ was held well up in its 
normal position. Through the opening in the side, the peritonaeum 
lining the abdominal wall and the under surface of the diaphragm, 
as well as the capsule of the organ, were throughly scarified. Iodo- 
form gauze was freely packed between the spleen and the abdominal 
wall, and the median incision sutured layer by layer with buried 
catgut. 
Drs. Howard and Woodward, surgeons to the hospital, conducted 
the after-treatment, and I did not see the patient until some two 
months afterward. She made a rapid and uninterrupted recovery 
without an untoward symptom. The median incision healed per 
primam ; the gauze tamponade was gradually withdrawn, and, when 
adhesion was found complete, the-suspending loop was removed. 
When 1 saw her, the organ was firmly held in place and all her 
symptoms had disappeared. 
The firmness of such peritoneal adhesions is too well known to 
require comment. In anchoring the kidney plastic inflammation is 
encouraged by many operators, but the stitches are needed besides, 
as the scar of connective tissue will yield very much more readily 
than the adhesions of a serous surface. 
V.-Excision of recurring mammary carcinoma ; closure of defect 
by sliding flap and skin grafts ; healing: 
Miss R. C. W., 44 years of age, had the left mamma removed by 
the "dinner plate" incision at the Hahnemann Hospital in Febru- 
ary, 1892. The large wound healed very slowly by granulation, 
the cicatrix breaking down and closing again and again, until a re- 
currence showed itself in the adherent scar. 
The growth together with the entire cicatrix were excised, the 
incision being carried 'into healthy tissues. The pectoralis major 
was removed entire, and the axilla, which had been cleaned out at 
the former operation, opened, but found free from disease. 
The patient having a fair amount of adipose, and the skin being 
freely movable, a curved incision was carried around the side to the 
back, and a large flap slid over the raw surface. The wound was 
closed with a buried suture of fine iron-dyed silk without drainage, 7 
except at a spot, one and a half by three-quarters of an inch in size, 
which the Hap would not cover. This was closed by Thiersch grafts 
taken from the thigh. As usual the most rigid antisepsis was em- 
ployed, and the wound dressed with iodoform gauze wrung out of 
bichloride solution, wet sublimated gauze, sterile sheet cotton, band- 
ages and adhesive strips. The grafts were dressed with protective 
changed every other day. They all took. The wound healed with- 
out reaction or pus, and this in spite of the formation of two sloughs 
from tension, which were kept aseptic by frequently-changed wet 
bichloride dressings. The small defects left by their removal healed 
by granulation. These, as well as the wound and Hap are shown in 
Fig. 3. The silk has not been heard from. 
The resulting cicatrix is very satisfactory, being but moderately 
adherent, and containing a minimum of scar tissue, while the enor- 
mous defect is covered with normal, soft, pliable skin, with a good 
padding of fat, and shows no tension, which annoys such patients 
very much when a large wound like this heals by granulation. This 
plan has been followed now quite extensively in my private practice 
and in my hospital service, and I find that it gives the ideal result. 
Whenever practicable, in any portion of the body, after a defect is 
left by any operation, I have recourse to this plan of sliding flaps. 
Next to it and far superior to the cicatrix resulting from healing by 
granulation is the method followed in case VI. 
VI.-Excision of carcinomatous breast; immediate closure of defect 
by skin grafts ; healing : 
Miss C. Z., set. 54, private patient at the Hahnemann Hospital, 
operated September, 1892. Examination showed the right mamma 
to be completely filled with a stony-hard growth, which was after- 
ward found histologically to be a carcinoma with excessive stroma. 
The skin was not ulcerated, there was some fixation to the chest- 
wall, and several nodules could be felt in the axilla. The breast was 
removed by the " dinner plate " method, the pectoralis major ex- 
cised, the minor pectoral divided (Halstead), and the entire axilla 
thoroughly cleaned out. A number of infected glands of varying 
size were found. The enormous wound was drawn together as much 
as possible, with interrupted sutures of silk and a continuous buried 
suture of catgut. The patient was so thin and the skin so inelastic, 
that a large raw surface remained, and sliding flaps were out of the 
question. Thiersch grafts were at once taken from the thigh, which 
had been previously prepared, and the entire defect covered with 
them. Hartley's razors answered admirably for this purpose. The 8 
sutured wound was dusted with iodoform-boric-sublimate powder, 
the grafts covered with strips of sterilized protective taken from salt 
solution, and the whole dressed with sterile gauze, woodwool, and a 
bandage held in place with adhesive strips. The grafts were dressed 
every other day and "took" with one exception, this defect being 
closed by Reverdin grafts kindly supplied by one of my students. 
The rest of the wound healed under one dressing, and her physician, 
Dr. G. D. Woodward, of Camden, N. J., reports no recurrence as 
yet. Unfortunately an early photograph was not obtained. I have 
employed this method, suggested by Watson Cheyne, in a number of 
cases, and can heartily recommend it where sliding flaps are unavail- 
able. Either of these plans hastens healing immensely, and does 
away with the deplorable " invitation to return " held out by the 
ordinary slow process of granulation, with its easily ulcerating scar 
tissue, long continued irritation, adherent cicatrix, and painful con- 
traction and contractures. t 
VII.-Excision of carcinoma of the cheek; closure of defect by 
sliding flaps ; healing : 
R. S. D., set. 48, private patient, operated at the Hahnemann 
Hospital. An epithelial carcinoma of the right cheek and side of 
the nose was excised in June, 1893, leaving the defect shown in 
Fig. 4. The ulcer had been previously treated with caustics, caus- 
ing extensive cicatricial contractions in the surrounding tissues. As 
a measure of safety, the dissection was carried so deeply that the 
nasal cavity was laid open. The extent of this opening is shown 
in the photograph. 
A week later, a flap was formed by a curved incision in the cheek, 
carried downward and outward, which was slid over to close the 
defect. The result is shown in Fig. 5. 
Owing to tension, or, more probably, to impaired blood supply, the 
portion of the flap covering the nose sloughed, leaving the nasal 
cavity open. After healing was complete, another flap was dissected 
off of the above flap, under cocaine, and slid over this defect. This 
apparent mishap was really a fortunate occurrence, for the sliding 
of the second flap thinned the cheek which was thicker than the 
other side, and gave a slope to the nose, which was obliterated by 
the original thick flap. Rapid healing followed the second plastic 
operation, and the patient was sent home to the western part of the 
state with a small sinus communicating with the nasal cavity. Un- 
fortunately, I have not yet received the final photograph which would 
show a decided improvement on Fig. 5. 9 
VIII. -Excision of recurring carcinoma of the right side of the 
neck (secondary to carcinoma of the lower lip) with resection of the 
lower jaw ; closure of the. defect by sliding flaps ; healing: 
W. A. L., set. 65, patient of Dr. T. O. Clements, of Dover, 
Delaware. Two years previously I removed a large carcinoma of 
the lower lip, closing the defect by the sliding method of Celsus, 
using a higher incision of the mucous membrane to form a new lip. 
The scar of the operation shows in Fig. 6. Six months previously, 
Dr. John E. James, my surgical colleague in the Hahnemann Hos- 
pital, removed, by an extensive and thorough operation, a number 
of cancerous glands from the right side of the neck. The wound 
did not heal, and he returned again in March, 1893, presenting the 
appearance shown in Fig. 6, and insisting on another operation. 
Excision of the growth necessitated a resection of over half the 
lower jaw, which was, so to speak, eaten into, and a careful dissec- 
tion of the tissues attached to the larynx, oesophagus, and great ves- 
sels of the neck. The mouth was opened, too, to a large extent. 
The resulting cavity is shown in Fig. 7. The wound was packed 
with iodoform gauze, and, a week later, a flap was loosened, by a 
curved incision, from the side and back of the neck, and slid over 
to cover the defect. The tension was so great as to produce symp- 
toms of asphyxia, and the nurse was instructed to cut the sutures 
should such a condition become imminent. The elasticity of the 
skin was sufficient, however, to allow of rapid primary union, and 
and the patient was discharged with a small fistula communicating 
with the mouth. Fig. 8 is from a photograph taken a few days 
since, when complete and definitive healing had taken place. The 
only visible defect is the absence of the beard on the flap which came 
from the back of the neck. In another photograph, showing the 
full face, this is not noticeable. 
IX. - Crushed foot; gangrene of three toes and dorsum of foot; 
amputation of toes and removal of slough ; skin grafts ; cure : 
R. D., set. 17, Italian laborer, was sent to the Hahnemann Hos- 
pital by Dr. Thomas Reading, of Hatboro, Pa., in June, 1893. A 
large stone had fallen on his left foot, crushing the. three inner toes 
and the dorsum of the foot, and fracturing the two inner metatarsal 
bones. The three toes soon became gangrenous, and the process 
spread rapidly up to the ankle, involving almost the entire breadth 
of the foot. The parts were dressed antiseptically, and carefully 
watched, until the line of demarcation was clearly defined, when he 
was operated. 10 
The three toes were amputated, and it was found possible to par- 
tially cover the heads of the metatarsal bones by forcibly drawing 
forward the sole. The slough on the dorsum was dissected off, and 
the skin drawn together from the sides and down from the ankle, 
with considerable tension, to reduce the defect as much as possible. 
Two weeks later, after the surface had been prepared by fre- 
quently changed, wet, bichloride dressings, and the foot and thigh 
had been thoroughly scrubbed and disinfected, he was etherized and 
the granulating surface covered with Thiersch skin grafts. They 
were treated in the ordinary manner, and every one took. The re- 
sulting cicatrix, after complete healing and contraction, is shown in 
Fig. 9. He was discharged with a perfectly useful foot. 
X.-Crushed elbow ; excision; close suture; superficial gangrene; 
skin grafts ; cure: 
C. D., age 19, was brought by the patrol to the Hahnemann Hos- 
pital, August 1, 1893. His left arm, at the elbow, had been run 
over by a horse car. The lower end of the humerus and the upper 
end of the ulna and radius were ground almost to a powder; the 
muscles and skin were extensively crushed and torn, and, with an 
intimate admixture of dirt and grease, resembled a filthy pulp. The 
wound and arm were scrubbed and disinfected vigorously and thor- 
oughly, the cavity packed with sublimated-iodoform gauze, and the 
whole put up in a wet bichloride dressing. I saw the case the next 
day, and, finding pulsation at the wrist, at his urgent solicitation, 
after he had been impressed with the probable dangers, decided on 
a conservative course. 
The comminuted joint was cleaned out, leaving smooth humeral, 
radial, and ulnar stumps, and the cavity allowed to fill with a blood 
clot. After careful trimming, the muscles and deep fascia were 
closely sutured with iron-dyed silk. The ulnar nerve was isolated 
and preserved. The skin and subcutaneous tissues were crushed 
beyond recovery, but, guided by former experience, I decided to 
continue the close suture without drainage, relying on keeping the 
slough aseptic. 
Besides, in carefully watched hospital cases, even if infection takes 
place, it is an easy thing to open a wound and arrest the process. I 
have gone so far in this direction as to amputate a forearm, at the 
edge of a stinking, sloughing, phlegmonous erysipelas; pack the 
wound, and, at the end of three days, closely suture it without 
drainage. Healing followed with but slight suppuration, and this 
in spite of the fact that the pysemic process had affected the opposite 11 
elbow, and the patient when operated was in a low, muttering de- 
lirium, and in profound collapse. 
The pulpy skin was accordingly sutured with buried silk, without 
drainage,and the arm put up in wet, sublimated dressings; the inner 
layer iodoformized. They were frequently changed. 
All the tissues, down to the deep fascia, over the posterior surface 
of the elbow became gangrenous and were removed as soon as loose. 
The extent of this superficial necrosis is shown in Fig. 10, in which 
are also seen the Thiersch skin grafts. In spite of this process the 
muscles and fascia united by first intention without being infected, 
and presumably the moist blood clot remained intact. There was a 
smart febrile rise for the first few days, reaching 102°, but a careful 
study of this showed only a slight zigzag, no more than could be 
accounted for by the necrotic process; so the deeper portions of the 
wound, and, for that matter, the superficial portions too, were not 
touched. 
Eighteen days after the first operation the sloughs having been 
cleaned off and the granulating wound thoroughly disinfected, the 
whole defect was covered with grafts taken from the thigh. Their 
appearance is shown in Fig. 10. Unfortunately, only about three- 
fourths of them took, this partial failure being due, I am sure, to 
faulty technique in the primary or subsequent dressings. At the 
close of my hospital service for this year, September 1st, this portion 
of the wound was rapidly cicatrizing, and, judging from the function 
already present, and the results obtained in two almost identical 
cases last spring, I think he will have a useful arm. 
The granulating wound, before and after the use of grafts, was 
dressed with a 5 per cent, emulsion of balsam of Peru in castor oil, 
well rubbed into absorbent sterilized gauze. This was covered with 
occlusive material, such as sheet cotton, wax paper, or oiled silk. I 
have experimented quite extensively, in the dispensary and hospital, 
with this dressing, suggested by Van Aredale, for granulating 
wounds, and with such satisfactory results as to lead me to adopt it 
in private practice. 
Apropos of the primary rise of temperature, the following recent 
case at the Hahnemann Hospital seems in point: 
A large suppurating lymphoma of the groin and Scarpa's triangle 
was thoroughly excised, the greatest pains being taken to render the 
cavity sterile by mechanical as well as chemical means. A close, 
buried suture of silk was then made, allowing the underlying cavity 
to fill with a blood clot, a small gauze drain being slipped into the 12 
lower portion of the wound which was not considered completely 
aseptic, and which had been shut off from the rest with the suture. 
The temperature rose rapidly to 106°, and then very slowly, but 
steadily, came down without any zigzag. The wound was inspected 
daily until the temperature became normal, but there being no signs 
of inflammatory reaction it was not opened. The blood clot filling 
the large cavity probably caused the "aseptic fever" of "fibrin ab- 
sorption." At the end of two weeks the gauze drain was removed 
from a small granulating sinus, the rest of the wound being com- 
pletely healed per primam.