148 ELEMENTABY OPEEATIOiN'y. 



the first consideration to be noted is, that the wound must, of 

 coiirse, be thoroughly cleaned, and free from blood or foreign 

 bodies. Then the borders of the wound must be fresh, or, if old, 

 blackish, or beginning to granulate, must be sUghtly excised by 

 thia scraping, and the edges brought as closely iu contact as 

 possible. 



To apply the suture, the needle is to be held and used precisely 

 like an ordinary sewing needle. If the skin is thick enough to requii-e 

 it, a thimble can be used. Sometimes special needles with handles 

 are made, and sometimes forceps may be needed to grasp the 

 needle, and push or pull it through the integument. The needle 

 should pass through the skin as nearly perpendicularly as possible, 

 since, if introduced too obliquely, the tractions upon the skin may 

 be sufficiently uneven to involve the possibUity of tearing out the 

 stitch. In placing the suture, nerves, tendons and blood vessels 

 must, of course, be avoided. The suture should embrace a good 

 hold of the skin to secure a greater traction and better approxi- 

 mation of the parts ; the distance between the stitches must be 

 such that no gaping can take place ; they must be disposed at 

 regular distances apart. "When the needle is introduced from 

 vsdthout inward, the skin is raised with the fingers of the left 

 hand, or, better, with a forceps ; if introduced from within out- 

 ward, pressure is to be made upon the skin vsdth the fingers or 

 the blunt blade of a pair of scissors, neax the point of exit of the 

 needle. 



Generally, the suture is begun at the middle of the wound, in 

 which case the edges are made to meet more accurately and regu- 

 larly. This rule, however, will find numerous exceptions. All 

 the stitches should be placed before any are tied, and they must 

 be tied only sufficiently tight to keep the edges together; other- 

 wise they may cut throxigh the skin. If not sufficiently tight the 

 wound will be left gaping and cicatrization -will be interfered with. 

 The knots ought to be placed as much as possible on one side of 

 the wound and towards the most dependent part, to avoid their 

 being soiled by the suppuration. 



The material used for sutures varies much. Strong hnen 

 thread, sUk, metallic wires of silver, lead or tin, and in some cases 

 narrow and thin elastic cords or bands are used, according to the 

 circumstances. MetaUic wires have the advantage of being less 

 irritating, and can remain in the thickness of tissues without giv- 



