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section is nearly completed, the bone is broken with slight force.

Place the limb in the desired position, and close the wound, providing for drainage.

WIRING OF BONES.

a

EXAMPLE: Fractured Patella. - Prepare the subject by fracturing or subcutaneously dividing the patella and separating its fragments by flexing the kneejoint. Place the subject on the back.

Make a horizontal incision from the posterior part of the lateral surface of one condyle of the femur across the front of the joint, to the corresponding point on the other condyle. The incision should cross the joint on the level of the upper margin of the lower fragment of the patella. Divide all the tissues, thus freely opening the joint. Turn the fractured surface of each bone upward, and make them smooth by means of a bone-scoop.

Enter a bone-drill in the middle line of the anterior surface of the patella, a third of an inch from the anterior margin of the fractured surface. Bore the bone obliquely, piercing through the fractured surface near the layer of cartilage which covers its posterior surface. After each fragment is perforated, a stout silver wire is pushed through the track of the drill, following the point of the drill as it is withdrawn. A single wire is sufficient.

sufficient. Approxi- . mate the fragments by drawing the ends of the wire forward. Use care to be assured that no tissue nor foreign substance is included between the fractured surfaces. Twist the ends of the wire together until all the slack is taken up.

Cut the twisted ends of the wire one half inch from the surface of the patella, and bend them down against the bone, a cut through the periosteum being made over the bone to receive them. Cut along the wire as it lies over the patella, so that the wire can be pressed flat against the bone.

Provide for drainage from the joint at the two angles of the wound. Stitch accurately together the capsule of the joint and the tissue on the fragments of the patella, by means of a continuous suture of cutgut. The joint is thus closed and separated from the wound of the superficial tissues. Close the superficial wound, after providing for drainage. No vessels of importance are divided in this operation.

EXCISION OF THE SUPERIOR MAXILLA.

Place the subject on the back, with the head slightly elevated on a block. Operate from the righthand side, facing the subject.

Extract the middle incisor tooth of the bone to be removed. Make an incision through the median line of the upper lip to the septum nasi, and extend it into the nostril of the side from which the bone is to be excised. Curve the incision around the corresponding ala, and extend it upward in the furrow between this side of the nose and the cheek, to a point one half of an inch below the inner canthus of the eye. Join to the upper end of this incision an incision extending just below the inferior margin of the orbit to the malar bone (Fergusson). These incisions should divide all the tissues to the bone. Ligate the divided angular artery. Dissect the tissues from the bone, leaving undivided the reflexion

of mucous membrane from the external surface of the alveolar process to the flap.

Begin at a point one half of an inch from the middle of the posterior margin of the hard palate to make an incision through the periosteum extending along the median line to the space caused by the ex

. traction of the middle incisor tooth. Extend this incision up over the alveolar process until it meets the incision dividing the upper lip.

Separate the ala and side of the nose attached to the nasal process of the bone, and retract these parts in toward the septum. Incise the tissues on the floor of the nostril along the side of the septum, and, with a narrow saw, divide the alveolar process and hard palate in this line.

Strip up with an elevator the periosteum from the floor of the orbit, and expose the spheno-maxillary fissure. Protect the eye by holding the tissues of the orbit upward with the elevator, while the nasal process is sawn through to the internal inferior angle of the orbit. Divide with a scalpel the floor of the

. orbit from the internal inferior angle to the sphenomaxillary fissure, cutting close to the margin. Saw from a point opposite the spheno-maxillary fissure the malar bone downward and outward, just internal to the most prominent part of the bone.

Cut with a scalpel the mucous membrane reflected from the external surface of the alveolar process to the flap formed by the cheek, to a point posterior to the last molar tooth. Make a transverse incision through the periosteum, joining this incision behind the last molar tooth to the median incision through the hard palate.

Grasp the bone by means of lion forceps and force it down, to break the palatine and pterygoid attachments. Twist the bone and tear it from its other attachments.

Cut the superior maxillary nerve short, and ligate the internal maxillary artery in the location of the spheno-maxillary fossa.

The cutting forceps may supplement the use of the saw, and a saw may be used to divide the floor of the orbit instead of the scalpel.

An excision leaving the inferior margin of the orbital fossa may be made The operation is performed in every respect like the last, except in separating the bone superiorly. Drill or trephine the antrum just below the middle of the inferior margin of the orbital fossa, so as to admit a narrow saw. Proceeding internally, saw horizontally the anterior wall of the antrum and through the nasal process into the nasal fossa. Proceeding externally, saw horizontally through the anterior wall of the antrum and obliquely downward and outward when the malar bone is reached.

An excision may be performed, leaving the intermaxillary bone. In this case the canine tooth is drawn, and the alveolar process sawn through the incisor fissure. The other steps of the operation are the same as those just described. These excisions

may

be practiced sub-periosteally, by incising the gum down to the bone along the alveolar process internally and externally, just above the teeth. Join the incisions behind the last molar, and through the space left after either the incisor or canine tooth has been extracted. Separate the tissues from the external surface of the alveolar process, leaving them attached to the flap. Separate the tissues from the internal surface of the alveolar process, and from the hard palate as far as the median line. In the operation where the intermaxillary bone is to remain, an incision is carried from the socket of the extracted canine tooth to the median line following the incisor fissure. In sawing the alveolar process and hard palate, be careful that the gum and periosteal flap are protected. In stitching together the wound, the flaps removed from each side of the alveolar process are brought in apposition.

The part of the facial flap made by dividing the upper lip will need stitches of relaxation.

If both bones are removed simultaneously, the same incisions (Fergusson) are to be made on the other side. Separate the septum from the nasal crest. The two maxillæ are not to be sawn between, but removed together.

EXCISION OF THE INFERIOR MAXILLA.

Place the subject on the back, with the head slightly raised upon a block. Stand on the righthand side, facing the subject.

First, one half of the bone is removed as follows: Extract the middle incisor tooth of the half to be removed. Make an incision through the middle of the lower lip to a point just below the symphysis menti, cutting down to the bone. Join to the lower end of this incision another extending along the lower bor. der of the body, around the angle, and upward, immediately posterior to the ramus of the bone, until the level of the lobe of the ear is reached. The fa

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