106 SUTURING WOUNDS. 



Sutures must be so inserted as to bring the lips of the wound 

 into close contact at all points, and it is better to err on the side of 

 using too many than too few. In mucous membranes, bowel, etc., 

 more sutures are necessary than in the case, say, of skin. Their 

 distance apart ranges between three sixteenths and three eighths 

 of an inch. The points of entrance and exit should be at equal 

 distances from the borders of the wound, and in the case of the skin 

 not less than three eighths of an inch. The old rule, however, that 

 the needle should be inserted at a distance from the edge equal to 

 the depth of the wound, so that the surfaces should touch throughout 

 their extent and no open space remain below the suture, is not 

 always to be followed ; one is sometimes obliged to seek primary 

 union of the skin, leaving union of the depths to follow by granu- 

 lation. A drainage-tube may then be inserted to facilitate discharge, 

 care being taken to select the most dependent point for its exit ; 

 but considerable doubt has been thrown on the efficacy of drainage- 

 tubes, and after being replaced by gauze, plaited horsehair, etc., 

 they have been finally abandoned by a good many operators. They 

 are, however, useful in properly selected cases. Retention of dis- 

 charge must be carefully prevented, because not only would such 

 discharge prevent immediate contact of the deeper surfaces of the 

 wound, but it would greatly favour the multiplication of micro- 

 organisms. 



When rapid healing of deep wounds is of great importance, the 

 deeper seated structures should be united with aseptic material, 

 and the threads cut short before the skin wound is closed. These 

 " buried sutures," if aseptic, cause neither irritation nor suppuration. 

 In penetrating wounds involving the peritoneum the serous surfaces 

 must first be brought together, then the muscles, and finally the 

 skin ; similarly in extensive wounds of tendon sheaths and joints, 

 the tendon sheath or capsule of the joint is first to be united and 

 afterwards the skin. 



To avoid displacing the margins sutures should be inserted at 

 right angles to the long axis of the wound. They should merely 

 bring the surfaces into contact and hold them together ; the most 

 frequent error in this respect is to draw them too tight, causing them 

 to cut out or even to produce local necrosis of the lips of the wound. 

 They should be left in position until the new tissue has become 

 sufficiently firm. Primary union occurs within three to five days 

 or not at all ; the changes in the wound after this time only influence 

 the firmness of the cicatrix. The usual direction, to remove sutures 

 between the fourth and sixth days, without reference to the size, 



