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which holds the needle, and the double end made by cutting the needle loose from the ligature. Before making the last stitch, pull several inches more of the ligature through the eye of the needle, so that the free end will not be carried through the puncture when the needle makes it exit.

The quilled or button, the twisted, and the quilt sutures, are sutures of relaxation, and require the glover's or interrupted suture to be used in conjunction to appose the more superficial parts of the wound.

If wire is used as a suture, the ends are twisted together, and the twisted portion of the suture is placed as the knot of the silk ligature, away from the line of incision. Make the wire lie flat across the wound by bending it to make an angle at the entry and exit. The ends may be clipped to one quarter of an inch, or all run into a piece of rubber tubing.

The suture must be cut near the twist when it is to be removed. Straighten as much as possible the wire and run it into the slit of an applicator. Press the applicator firmly enough to prevent any force being exerted on the flap, while the twist of the suture is caught in the forceps and steadily drawn upon. .

Always aim at having no more strain on sutures than is required to establish perfect coaptation without any wrinkling of the lips of the wound.

6. The special sutures for organs covered by serous membrane will be practiced in connection with the operations performed upon the intestine. The needles should have rounded edges.

(a) Lembert's Suture.—Enter the needle about one third of an inch from the cut edge and pierce a fold of peritonæum. This fold should include nearly a quarter of an inch of the peritonæum between the point of entrance of the needle and the cut edge. Enter the needle near the other edge, and pierce a similar fold of peritonæum exactly opposite. Invert the edges of the wound, and either make the suture continuous or interrupted.

This suture brings into contact narrow surfaces perpendicular to the cut margin.

(6) Gely's Suture.* -Enter the needle about a quarter of an inch from the margin and advance it parallel to the wound, piercing a fold of peritonæum. The entrance and exit of the needle should be separated about a quarter of an inch. Enter the needle on the other side, at a point corresponding to the exit, and pierce a similar fold of peritonæum, bringing the needle out at a point opposite and corresponding to the first entrance of the needle. The beginning and ending of the suture are thus opposite each other across the wound, and are to be secured by a knot after the edges of the wound have been inverted.

A continuous Gely's suture may be made by threading a needle on each end of a ligature and then entering the needles on opposite sides of the wound at corresponding points. Take up similar folds of peritonæum by advancing the needles parallel to the edges of the wound. The two needles may now change sides, or, better, the ends may be tied and the suture made secure. The needles must enter at the points of exit of the last suture, and similar folds of peritonæum be pierced as before.

* These sutures, if made to pierce into the lumen of the gut, are objectionable.

This suture secures the contact of a surface of peritonæum extending parallel to the wound.

(c) Jobert's Suture.—Strip the mesentery two thirds of an inch back from the ends of a divided gut. Insinuate into the lumen of the upper gut one end of a piece of tallow-candle, and into that of the lower the other end of the candle. Pierce the upper end of gut from without inward, about a quarter of an inch from the margin through the surface from which the mesentery was stripped. Invaginate one half inch of the cut end of the lower gut into its own lumen. Pierce the invaginated gut near its cut margin, and the invaginating gut lying over it, from within outward through the surface from which the mesentery was stripped.

Similar sutures are to be passed all around the whole circumference of the divided ends of the intestine. The upper ends of the ligatures are now passed through the lower gut near the folded margin. The candle is slipped down the alimentary canal, and the ends of the ligature are secured.

Serous surfaces are brought into contact except where the mesentery was attached, where raw surfaces are apposed.

The divided upper gut is invaginated into the invaginated portion of the lower divided gut, imitating intussusception.

(d) Double Continuous.—This is the ordinary continuous suture carried around the circumference, and then continued back in the middle of the spaces left between the former entrances and exits of the ligature.

The edges are inverted to bring together serous surfaces.

(e) Czerny's suture may be used in connection with most of the foregoing sutures with advantage. Enter the needle through the peritoneal surface near the margin of the wound, and bring it out through the wound-surface near the edge of the mucous membrane. Pierce the opposite wound-surface near the mucous edge, and bring the needle out through the peritoneal surface near the margin of the wound. Invert the peritoneal edge of the wound and secure the ends of the ligature by means of a knot.

These stitches are to be made one eighth of an

inch apart.

KNOTS.

1. Reef.Knot.-The reef-knot is a double knot. The first knot is made by making a loop and carrying the end of the ligature held in the right hand forward over the end held in the left hand, so as to be turned through the loop backward. The second knot is made (the ends of the ligature having changed hands) by carrying the end held in the right hand backward over that held in the left hand, so as to be passed through the loop forward.

The second turn of the knot should not be drawn upon with great force.

2. Surgeon's Knot.—This is a double knot having the end of the ligature turned through the first loop twice. The second knot is made by turning the end of the ligature in the same manner once through the second loop.

The first knot, having two turns, is not liable to slip.

CHAPTER IV.

OPERATIONS ON THE HEAD AND NECK.

TREPHINING.

Crown Trephine, Galt: Trephine.* SHAVE the part. Make semilunar, crucial, or ishaped incisions down to the bone, and raise all the tissues in flaps with a periosteum elevator. Make the flaps sufficiently large to expose a surface of bone which will allow the crown of the trephine to be applied. Hold the flaps from the wound by tenacula, or by ligatures passed through them near their edges. Project the central pin of the trephine slightly beyond the crown, and make it fast. Hold the handle of the trephine between the palm of the hand and the middle, ring, and little fingers, and apply the thumb and index-finger along the shaft.

The operator must work from a higher level than the part to be trephined, in order to bear upon the instrument.

Place the central pin of the trephine in the center of the surface, and with a few turns of the handle from left to right and right to left, and with slight pressure, make it bore into the bone. After a few more turns, the instrument being held perpen

* See chapter x, use of saw.

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