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and then transfixing and cutting outward, or by cutting the fold from the surface to the desired extent.
In making the incision deeper, make the cuts of the same length as the first, and as important structures are approached use the director. With a pair of thumb-forceps pinch up very superficially the tissue at the bottom of the wound. Nick the tissue as close to the ends of the forceps as possible, the scalpel being held short, with the blade flatwise to the surface, and making a right angle with the forceps. Enter the end of the director into the opening formed, and gradually, with slight pressure and lateral movements, introduce it to the angle of the wound. The end of the director should be inclined slightly, as if to push through, the layer of tissue being raised during its introduction. Place the point of the knife into the groove, and incline the handle toward the director as much as possible, without allowing the point to escape the groove. Advance the knife held in this manner with a slight sawing motion, until its point is arrested in the cul-de-sac at the end of the groove. Raise the handle of the knife to the perpendicular position to divide completely the tissues up to the angle of the wound.
This procedure is repeated in order to divide the tissues to the other angle of the wound.
Let each cut advance the operation systematically.
If a loose layer underlie a fascia, as is the case with the peritoneum, be careful that a fold of the underlying tissue does not override the point of the director.
Tissues overlying the director should be examined before being divided.
The overlying tissues may be divided with scissors, one blade being kept in the groove. Hold the scissors with the thumb and middle fingers in the rings, and the index-finger on the blade to direct.
To illustrate this principle, prepare a piece of rubber tubing with free openings cut into its lumen along its sides at short intervals. Introduce, if necessary with a probe or thumb-forceps, one end of the tubing down to the bottom of the wound. This end must be cut slanting, to facilitate its introduction. Bring the other end out of the most dependent part of the wound. Fasten a safety-pin through the tubing as it leaves the wound, or pierce the tubing with a needle carrying a ligature, which is to be tied loosely around the member, or fastened by plaster to the surface. Cut the tubing flush with the surface.
Introduce in like manner a piece of prepared tubing into the superior angle of the wound and se
Strands of horse-hair, long enough to extend beyond the angles of the wound while lying in its deepest part, or, when doubled, to reach from the bottom to the most dependent angle of the wound, may be used to illustrate correctly the principle of drainage.
Patulous openings can be made by removing a column of tissue, with an instrument cutting like a leather-punch, from the deeper parts of the wound to the surface in dependent positions (canalization).
1. The continuous or glover's suture is made by piercing one lip of the wound from without and the other correspondingly from within, thus bringing the armed needle out, so that the points of entry and exit are opposite and equidistant from the margin.
When the next and subsequent stitches are to be taken, the needle is entered on the same side as for the first stitch, and at equal distances apart. The ligature extends diagonally across the line of the wound from one point of exit to the next of entry.
Care must be taken to pierce the integument per: pendicularly
Use a curved or half-curved needle, if the stitches are to run deep through the tissues.
The left hand steadies and affords counter-pressure, enabling the needle to pierce the tissues.
Accurate apposition of thin-lipped wounds is best attained by this suture where there is little force required to maintain coaptation.
To remove this suture, cut each diagonal turn at its entry and then withdraw by means of forceps, holding the left index-finger applied closely to the point of exit to prevent the lip of the wound from bearing any strain.
When these sutures are used to bring together the deeper parts of a wound, they are called buried sutures.
2. The interrupted suture is made like the continuous, except that it does not run from one exit to the next entry of the suture, but is cut after each complete passage of the needle, and the two ends are united by a knot. The knots should fall on one side of the wound, either the side of the entries or that of the exits of the sutures.
To remove the suture, cut the ligature at its point of entry if the knot is over the exit, and then by means of forceps draw upon the knot, the left indexfinger being applied near the exit to prevent drag. ging on the lip of the wound.
3. The quilled suture is made by passing a stout needle, fitted into a handle, through the tissues from one side to the corresponding point of the other side of the wound. Thread the eye which is near the point with a double ligature, and withdraw the needle, thus carrying one end of the double ligature through to the other side of the wound. A curved needle is best adapted for making this suture. Through the loop of the double ligature pass a piece of catheter, and secure it by drawing on the double ligature from the other side of the wound. Tie the two free ends of the double ligature over a similar piece of catheter.
If a number of sutures are used, run a piece of bougie through all the loops, which will, of course, run parallel to the wound, and secure a similar piece of bougie on the other side between the ends of the double ligatures.
This suture holds the deeper parts in apposition ; hence, the pieces of bougie must be removed about an inch from the margin of the wound, to make the course of the ligatures as nearly straight as possible.
The continuous or interrupted suture is used, in conjunction with the quilled suture, to secure apposition of the superficial parts of the wound.
If buttons are used instead of quills, the suture is called the button-suture.
4. The twisted suture is made by passing metal pins through the lips of the wound. The pins should cross the wound as deep as possible, and, if the tissue is completely divided into flaps, they should pierce almost to the other surface. Enter the pins some distance from the margin, and bring them out at corresponding points on the other side of the wound. The pins being placed, wrap around them cotton yarn, in a figure of eight, making the crossings of the yarn correspond to the line of incision. As each pin is sufficiently wrapped, the yarn is continued diagonally from the lower turn of that pin to the upper of the next. Clip the points of the pins, and protect the skin by placing beneath the ends small pieces of adhesive plaster.
This suture keeps the whole surface of a wound in apposition, and from being used in hare-lip is called hare-lip suture.
The pins should be pointed, or a pin-carrier will be necessary (Buck, Post) to guide them into position.
5. The quilt or fold suture is made by passing the needle through the lips of the wound at equidistant and opposite points. A knot is now made, which must lie over the point of exit. Now enter the needle on the side through which the needle has just made its exit, and bring it out at a point exactly opposite and equidistant from the margin of the wound. In this suture the loops lie parallel to the wound.
Secure the last stitch, as in the case of the glover's suture, by tying together the free end of the loop