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ward the end of the finger, under the disarticulated base of the phalanx. Extend the finger and cut the palmar flap, keeping close to the bone and following the lateral incisions. Turn the edge of the knife perpendicularly to the flap and cut it off from the phalanx.

Remove any portion of the flexor tendon contained in the flap. Occlude the digital arteries. Close the wound by bending the palmar flap over the end of the second phalanx. Provide for drainage.

Amputation and Disarticulation of the Second Phalanx.

1. Amputation.—Make a circular incision through the integument and fascia, as near the end of the phalanx as possible. Divide the flap on each side, so that it can be rolled up like a cuff to the extent of one half the diameter of the phalanx. Divide the tissues circularly at the level of the base of the flaps. Saw the bone at a right angle to its long axis.

Occlude the digital arteries. Round off the an. gles of the flaps, and stitch the flaps accurately together, providing for drainage.

2. Disarticulation.—Make two lateral incisions as in disarticulation of the distal phalanx. In making the dorsal incision, divide only the integument and fascia over the line of the joint. Elevate a flap, including the common extensor tendon and the periosteum, from the dorsal surface of the second phalanx. This flap should be of sufficient size to cover the head of the phalanx. Disarticulate the bones and form the palmar flap, as in case of the distal phalanx.

Occlude the digital arteries. Cover the head of the bone with the periosteal and tendinous flap,

which in turn must be covered by the palmar flap. Stitch the palmar flap to the tissue on the dorsal surface, making the sutures in such a manner as to include the dorsal tendon.

Amputation and Disarticulation of the Proximal Phalanx.

1. Amputation.—This amputation is performed similarly to that of the second phalanx, except that a dorsal periosteal and tendinous flap should be secured of sufficient size to cover the sawn end of the bone. Stitch the dorsal tendinous flap to the divided flexor tendons. Stitch the palmar to the dorsal flap, providing for drainage.

2. Disarticulation.—This operation is best performed by a pyriform incision. The other fingers are separated from the one to be removed.

Begin an incision on the dorsal surface at the anterior extremity of the head of the metacarpal bone, and extend it obliquely downward toward the palmar surface, one quarter of an inch beyond the junction of the web to the finger. Make a similar incision on the opposite side of the finger. Join the ends of these incisions by a transverse incision across the palmar surface of the finger. These incisions should include the tissues to the bone. Join to the upper angle of this pyriform incision, an incision three quarters of an inch long, extending along the dorsal surface of the metacarpal bone.

Separate the tissues from the bone, without preserving the periosteum. Open the joint by a dorsal incision concave toward the body. Divide the lateral ligaments, and disarticulate the bones. Occlude the digital arteries.

The head of the metacarpal bone is often removed when symmetry is more desirable than strength.

In the case of the thumb or the index-finger, an external flap may be fashioned to cover the woundsurface, and an internal one in case of the little finger.

The heads of the second or fifth metacarpal bones should be cut off obliquely toward the contiguous bone.

The practice of set amputations or disarticulations of the metacarpal bones is of doubtful expediency. In amputating through these bones the bases of the second, third, and fifth should be preserved, on account of their tendinous attachments. In disarticulating the first metacarpal the saddle-shape of the articulation should be remembered, and the proximity of the radial artery. The sesamoid bones should not be included in the flap.

Disarticulation at the Wrist.Compress the brachial artery. Supinate the hand.

Begin an incision at the styloid process of the radius and extend it straight down in the palm of the hand to within one half inch of the level of the head of the second metacarpal bone. Begin a second incision at a corresponding point on the ulnar side of the wrist, and extend it into the palm to within one half inch of the level of the head of the fifth metacarpal bone. Join the distal ends of these incisions by means of a transverse incision across the palm of the hand. Divide the tissues until the flexor tendons are encountered.

Raise this rectangular flap from the palm up to the level of the wrist-joint. The pisiform bone and the unciform process of the unciform bone may be cut with bone-nippers, and afterward dissected from

the flap

nerves.

Pronate the hand, and connect the proximal ends of the longitudinal incisions by a dorsal incision slightly convex downward. Reflect this short dorsal cellulo-cutaneous flap to the level of the wrist-joint.

Grasp the hand and strongly flex the wrist. Divide the extensor tendons and open into the joint by an incision slightly convex toward the body. Divide the lateral ligaments. Retract the palmar flap, and divide with one sweep, not push, of the knife, all the flexor tendons. Cut short the divisions of the ulnar and median

Occlude the radial artery, and any small dorsal or palmar arteries which may be seen. The superficial arch is included in the palmar flap. The styloid processes may be nipped off. Stitch the palmar to the dorsal flap, providing for drainage.

Dubreuil's Operation.—Make a flap convex downward, whose base shall extend from the junction of the outer to the middle third of the wrist anteriorly, to a corresponding point on the dorsum. The lower convex border of the flap extends to the level of the head of the first metacarpal bone. Reflect this cellulo-cutaneous flap up to the level of the wrist.

Make an incision from one extremity of the base of the flap around the ulnar side of the wrist to the other extremity. Retract the cellulo-cutaneous tissue up to the level of the wrist, and remove the hand, as already described. Occlude the radial and ulnar arteries, and fit the flap to the surface of the wound, providing for drainage.

Amputation through the Forearm (circular). Compress the brachial artery. Extend the arm and hold it between supination and pronation. Measure the circumference of the forearm at the site of the amputation. The length of the flap should be one quarter of this measurement.

The operator, standing on the right-hand side of the limb, with his right foot forward, and stooping slightly, should carry the knife under and up on the other side of the forearm until, by extending his wrist, the edge of the knife lies horizontally on the upper surface of the limb. With a slight sawing motion the knife is made to divide circularly the integument and cellular tissue around the limb. As the knife cuts under the limb and on the side nearest to the operator, the handle describes an arc between the index-finger and thumb, so that at the completion of the incision it points forward. The operator at the same time assumes the erect position.

Elevate the flap, keeping the edge of the knife directed perpendicularly to the muscular tissue. Slit the flap in a line corresponding to the long axis of the ulna, so that it may be rolled up like a cuff to the desired extent. Make a circular division of the muscles at a level one half inch below the base of the flap. With a catlin form an interosseous flap as already described. Form periosteal flaps for each bone.

Retract the soft parts by means of a retractor, made by partially tearing into three strips a rather wide bandage. One of the strips should go between the bones, and lie over the other strips crossed above. Grasp with the left hand the limb just above the proposed division of the bone. Saw the bones, begin

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