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ning and ending on the more fixed. The radius is more fixed below, and the ulna above.

Remove any spiculum by means of the bone-nippers. Occlude the radial, ulnar, and the two interosseous arteries. Remember that the posterior interosseous artery lies between the superficial and deep layer of muscles. Provide for drainage, and stitch the flap accurately together, making the line of union vertical, rounding off the angles of the flap made by the ulnar incision, and where the flap is doubled upon itself superiorly.

In the middle of the forearm preserve, if possible, the insertion of the pronator radii teres muscle, and in the upper part the insertions of the biceps and brachialis anticus.

Disarticulation at the Elbow-Joint (circular).Extend the elbow and abduct the limb. Compress the brachial artery above the middle of the arm.

Measure the circumference of the limb around the joint, to determine the length of the flap. Remember that the line of the articulation is oblique, and is fully one half inch below the internal epicondyle.

Make a circular division of the integument and superficial fascia, as described in the last operation. Raise the flap and roll it up like a cuff above the joint. Forcibly extend the joint, and divide the tissues in front in the line of the joint obliquely down. ward and inward. Divide the lateral ligaments. Hy. perextend the joint and dislocate forward the olec

Retract the flap, and divide with a sweep of the knife the triceps tendon.

Occlude the brachial and the profunda arteries. Pull out and cut short the median, ulnar, and mus

ranon.

culo-spiral nerves. Bring the flap together vertically, and round off the superior and inferior folded angles. Stitch the apposed edges, providing for drainage.

Amputation through the Arm.—The amputation through the arm by the circular method is performed by following the same general rules already described.

This amputation should also be practiced by the flap method. Compress the vessels above the site of the proposed amputation. Abduct and rotate outward the shoulder-joint. Stand on the right-hand side of the limb.

Grasp the arm one inch below the proposed level of the saw-cut, between the left thumb and indexfinger. The thumb should be placed over the biceps, and the index-finger over the triceps muscle, the humerus being situated about midway between. Begin an incision just below the tip of the index-finger, and extend it downward the length of one half the diameter of the limb. Make a similar incision downward, from just below the tip of the thumb. Join the lower ends of these incisions by a transverse incision somewhat convex downward. These incisions should divide the integument and superficial fascia, which will immediately retract. Complete the internal flap by beginning at the level of the retracted integument to cut obliquely to the bone situated between the tips of the thumb and index-finger.

The brachial artery may be caught by means of forceps as soon as it is divided. The base of this internal flap thus formed includes the semi-circumference of the limb. The flap includes the inner bor. ders of the biceps and triceps muscles.

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Through the anterior angle of the wound push the point of the amputating-knife across the outer surface of the humerus—the edge of the knife being directed downward. Advance the point of the knife to the posterior angle of the wound, the tissues being pressed external to the track of the knife. Carry the knife downward along the external surface of the humerus with a free sawing movement, supporting the flap with the left hand. When the knife has reached a level about an inch below the extremity of the internal flap, turn its edge perpendicularly toward the surface, and form the extremity of the external flap by cutting directly to the surface.

Retract the flaps, and form a periosteal flap. Clear the bone, being sure that the musculo-spiral nerve is divided. Saw through the bone.

Occlude the brachial and the two profunda arteries. Draw upon the median, ulnar, and musculo-spiral nerves, and cut them off at the wound-surface. Stitch the flaps together, providing for drainage.

Disarticulation at the Shoulder-Joint (Spence).Place the subject near the edge of the table, with the back raised upon a high block. Compress the vessels in the axilla by the elastic tubing, as already described. Slightly abduct and rotate outward the limb.

Begin an incision, as for resection of the head of the humerus, a little above and external to the coracoid process, and extend it three or four inches down- . ward in the axis of the limb. This incision should divide the tissues down to the bone, uncovering the tendon of the long head of the biceps, and enabling the operator to inspect the shoulder-joint.

From the lower end of this incision make a transverse incision slightly convex downward, dividing all the tissues external to the humerus and extending to the posterior fold of the axilla. This incision cuts through the deltoid muscle just above its insertion.

Begin a second incision at the lower end of the vertical incision, and carry it transversely and slightly convex downward, around the inner side of the limb, to meet the external incision at the posterior axillary fold. This incision should only divide the integument and the subcutaneous fascia.

Elevate the deltoid portion of the flap up to the level of the acromion process. Rotate the limb inward, and, with a forcible sweep of the knife above the greater tuberosity, divide the capsule and the tendons of muscles, opening widely the joint. Rotate the limb outward, and divide the capsule of the joint and the tendon of the subscapularis.

Pass the knife over the head of the humerus to its inner side. Cut downward, following the humerus to the level of the divided integument on the inner side of the limb. Place the thumb between the flap and the humerus, and compress the axillary artery against the fingers of the same hand placed in the axilla. Turn the edge of the knife perpendicularly to the flap and cut straight through the tissues on the inner side of the limb.

AMPUTATIONS AND DISARTICULATIONS OF THE LOWER

LIMB.

Amputations and Disarticulations of Toes.—Compress the vessels of the leg during these operations.

The rules given for performing the amputations and disarticulations of the fingers are applicable to those of the toes. Disarticulations are to be preferred in operating on the toes, with the one exception of amputation through the proximal phalanx of the great toe.

In the disarticulation of the first metatarso-phalangeal joint the pyriform incision should cross the plantar surface of the great toe at least one half inch below the web, on account of the great size of the head of the metatarsal bone. It is preferable to remove the heads of the metatarsal bones after disarticulations.

Amputation and Disarticulation of Metatarsus.1. Amputation.Grasp the toes with the left hand, and stand facing the sole of the foot.

Make an incision through the soft parts from one side of the foot to the other, following the groove at the junction of the toes to the sole. Join to the ends of this incision two lateral incisions, one along the inner side of the foot over the first metatarsal bone, and the other along the outer side of the foot over the fifth metatarsal bone. These lateral incisions should extend to the level of the proposed amputation through the metatarsus. Reflect the plantar flap thus marked out, cutting close to the metatarsal bones.

Reflect a dorsal cellulo-cutaneous flap inverse in length to the plantar flap. The dorsal flap should be slightly convex downward, and its base should extend from one side to the other of the base of the plantar flap. Divide the dorsal tendons at the level of the base of the dorsal flap.

Incise the tissues in the interosseous spaces to al

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