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Raise an anterior convex flap, consisting of integument, and a moderately thick layer of muscular tissue, the length of two thirds the measurement of the circumference of the limb. Reflect a posterior cel. lulo-cutaneous convex flap, one third the circumference of the limb in length.

Divide the remainder of the soft parts circularly. Provide a periosteal flap and retract the tissues about two inches. Saw the bone. Occlude the femoral and profunda arteries.

Esmarch's Operation.—Raise two lateral flaps of moderate length. Divide all the soft parts circularly to the bone. Push up the periosteum to the extent of an inch or more, and saw through the bone.

Suture the periosteal flap over the end of the bone, and then the muscles together by means of buried sutures. Suture the flaps

Suture the flaps together, making no provision for drainage.

Disarticulation at the Ilip-Joint.Bring the nates over the edge of the table; control the vessels as described by means of the elastic tubing (Lloyd).

Jordan's Operation.—Hold the thigh at an angle of 45° with the axis of the body. Begin an incision three inches above the middle of the upper border of the great trochanter, and continue it downward, along the outer surface of the thigh, dividing all the tissues to the bone. Separate the periosteum from the bone down to the proposed level of division of the soft parts (Ollier).

Disarticulate the hip-joint as in resection. Divide the soft parts by the circular method at as low a level as possible.

Occlude the femoral and profunda arteries.

This method of amputating is applicable to the shoulder-joint.

Transfixion (Liston).—Place the subject so that the nates project beyond the table. Abduct the opposite limb, and lift up the scrotum. Slightly flex the hip-joint, and rotate the limb inward.

On the left side transfix the tissues in front of the joint, from a point midway between the anterior superior spine of the ilium and the great trochanter, to a point anterior to the tuberosity of the ischium. Guard against piercing through the foramen ovale. On the right side, the point of the knife is entered anterior to the tuber ischii.

Cut downward, following the bone closely, for five or six inches. (An assistant can now pass his fingers under the flap, and press the vessels against his thumbs, placed over the flap.) Turn the edge of the knife perpendicularly to the flap, and cut directly to the surface.

Abduct and rotate strongly outward the joint. The capsule may have been opened by the first thrust of the knife. Divide the capsule, and partially dislocate the head of the femur, when the ligamentum teres can be divided, and the disarticulation completed.

Pass the knife behind the head of the bone. Adduct and rotate inward, when the trochanter major will not interfere with the formation of a posterior flap four or five inches in length.

(Guthrie cuts the flaps from the surface toward the bone.)

Occlude the femoral vessels, the profunda, the obturator, and sciatic arteries.

INDEX.

Abdominis, paracentesis, 12.
Adductor longus, tenotomy of, 72.
Amputation of arm, 131.

of forearm, 129.
of leg, 140.
of metatarsus, 134.
of penis, 63.
of proximal phalanx, 126,
of second phalanx, 125.
of tarsus, 134,
of thigh, 143.

of toes, 133.
Ankle, disarticulation at, 138.
Antrum, perforation of, 34.
Arm, amputation through, 131.
Arteriotomy, 101.
Artery, ligation of axillary, 82.

brachial, 81.
common carotid, 85.
external carotid, 88.
internal carotid, 87.
deep epigastric, 94.
facial, 89.
femoral, 95.
gluteal, 92.
common iliac, 90.
external iliac, 94.
internal iliac, 92.
lingual, 89.
occipital, 90.
dorsalis pedis, 100.
peroneal, 99.
popliteal, 97.
internal pudic, 93.
radial, 80.
sciatic, 93.
subclavian, 83.
temporal, 90.
superior thyroid, 88.
anterior tibial, 99.
posterior tibial, 98.
ulnar, 81.

vertebral, 84.
Aspiration (Dieulafoy), 15.

Aural specula (Gruber and Toynbee), 1.
Axillary artery, ligation of, 82.
Bauden's operation, 142.
Bones, wiring of, 105.
Bougies, esophageal, 5.

rectal, 8.
Brachial artery, ligation of, 81.
Bronchotomy, 37.
Canalization, 20.
Carden's opération, 143.
Carotid artery, ligation of common, 85.

external, 88.

internal, 87.
Castration, 65.
Catheterization of Eustachian canal, 3.

of larynx, 4.
of uretbra, 5.

of posterior urethra, 61.
Catheter, tunneled, 7.
Chopart's operation, 137.
Circumcision, 62.
Colectomy, 49.
Colostomy, lumbar, 49.
Compression of vessels, 76.
Corneal paracentcsis, 10.
Cystotomy, lateral perineal, 58.
median perineal, 57.
suprapubic, 60.

Disarticulation at ankle-joint, 138.

at elbow, 130.
at hip, 145.
at knee, 141.
at metatarsus, 134.
of distal phalanx, 124.
of proximal phalanx, 126.
of second phalanx, 125.
of tarsus, 137.
of toes, 133.

of wrist, 127.
Drainage, 20.
Dubreuil's operation, 128.

Elbow, disarticulation at, 130.

Joint, resection at shoulder, 112.
Enterectomy, 46.

wrist, 115.
Enterorrhaphy, 46.

Jordan's operation, 145.
Enterostomy, with enterotomy or en-
terectomy, 48.

Knee, disarticulation at, 141.
Enterotomy, 47.

Knife, manipulation of amputating,
Epigastric artery, ligation of deep, 94. 122.
Esmarch's operation, 145.

Knot, reef, 27.
Eustachian catheter (Noyes), 3.

surgeon's, 27.
Excision of breast, 43.
of eye, 32.

Laparotomy, median, 44.
of inferior maxilla, 109.

Laryngotomy, 38.
of superior maxilla, 106.

Laryngo-tracheotomy, 39.
of tongue, 35.

Larynx, catheterization of, 4.
Extensor communis digitorum, tenoto- intubation of (O'Dwyer's tubes), 4.
my of, 69.

Leg, amputation through, 140.
longus digitorum pcdis, tenotomy of, Ligaments, shortening of round, 64.
70.

Ligation of arteries, 80.
quadriceps femoris, tenotomy of, 71. of vessels, 77.
primi and secundi internodii pollicis, Lingual artery, ligation of, 89.
69.

nerve, neurotomy of, 73.
Extraction of teeth, 32.

Lisfranc's operation, 135.
Eye, excision of, 32.

Lister's operation, 144.

Liston's operation, 146.
Facial artery, ligation of, 89.
Fasciatomy, plantar fascia, 72.

Mammary gland, excision 'of, 43.
Femoral artery, ligation of, 95.

Maxilla, excision of superior, 109.
Flexor cubiti, tenotomy of bicers, 69.

of inferior, 106.
carpi radialis, tenotomy of, 69.

Median nerve, suturing of, 74.
carpi ulnaris, tenotomy of, 69.

Metatarsus, amputation and disarticu-
longus and brevis digitorum, tenoto-

lation of, 134.
my of, 69.
profundus digitorum, tenotomy of, Nares, plugging of posterior, 8.
68.

Nasal duct, probing of, 4.
sublimis digitorum, tenotomy of, 68.

specula (Fraenkel), 1.
biceps femoris, tenotomy of, 71. Needle, hypodermic, 15.
biceps femoris, suture of tendon, 72. Nephrectomy, 52.

pollicis longus, tenotomy of, 68. Nepbrorrhaphy, 51.
Forearm, amputation through, 129. Nephrotomy, 52.

Neurectomy of spinal accessory, 73.
Gluteal artery, ligation of, 92.

Neurotomy of lingual, 73.
Gritti's operation, 144.

Nerve, stretching of great sciatic, 74.

suturing of median, 74.
Hip, disarticulation at, 145.
Hypodermic needle, 15.

Occipital artery, ligation of, 90.

Esophageal probang or bougie, 5.
Iliac artery, ligation of common, 90.

Esophagotomy, external, 41.
external, 94.

Oöphorectomy, 65.
internal, 92.

Operations, steps in, 123.
Intubation of larynx (O'Dwyer's tubes), Osteotomy, 104.
4.

Paraccntesis abdominis, 12.
Joint, resection at ankle, 120.

corneæ, 10.
elbow, 114.

pericardii, 11.
hip, 118.

thoracis, 11.
knee, 119.

tympani, 10.
metacarpo-phalangeal, 117.

urethræ, 14.
phalangeal, 117.

vesicæ, 12.

Pedis, ligation of dorsalis, 100.
Penis, amputation of, 63.
Pericardii, paracentesis, 11.
Perineal cystotomy, lateral, 58.

cystutomy, median, 57.

urethrotomy, external, 54.
Peroneal artery, ligation of, 99.
l'eroneus longus and brevis, tenotomy

of, 70.
Phalanx, disarticulation of distal, 124.

proximal, 126.

second, 125.
Pharyngotomy, 42.
Phlebotomy, 100.
Pirogoff's operation, 139.
Plantar fascia, fasciatomy of, 72.
Popliteal artery, ligation of, 97.
Probing nasal duct, 4.
Pudic internal artery, ligation of, 93.

Suprapubic cystotomy, 60.
Suture, continuous or glover's, 21.

Czerny's, 27.
double continuous, 26.
Gely's, 25.
interrupted, 21.
Jobert's, 26.
Lembert's, 24.
quilled, 22.
quilt or fold, 23.

twisted, 23.
Syme's operation, 138.
Symphysiotomy, 52.
Syringe, aural, 1.

rectal, 3.

Padial artery, ligation of, 80.
Rcctal bougie, 8.

specula, 3.
Resection at ankle, 120.

bones, articulating ends, 112.
elbow, 114.
bip, 118.
knee, 119.
metacarpo-phalangcal, 117.
phalangeal, 117.
of rib, 111.
of scrotum, 61.
shoulder, 112.
wrist, 115.
Rib, resection of, 111.

rum, 69.

Saw, manipulation of, 103.
Scalpel, manipulation of, 17.
Sciatic artery, ligation of, 93.

nerve, great, stretching of, 74.
Scrotum, resection of, 61.
Semimembranosus and semitendinosus,

tenotomy of, 71,
Shoulder (Spence), disarticulation at,

132.
Sounding for stone, 55.
Sounds, tunneled, 7.
Specula, aural (Gruber, Toynbee), 1.

nasal (Fraenkel), 1.
rectal, 3.

vaginal (Fergusson's, Sims's), 2.
Spinal accessory, neurectomy of, 73.
Sterno-cleido - mastoid, tenotomy of,

67.
Stomach-tube, 5.
Stone, sounding for, 55.
Strabismus, 30.
Subclavian artery, ligation of, 83.

Tarsus, amputation and disarticulation

through, 137.
Teale's operation, 140.
Teeth, extraction of, 32.
Temporal artery, ligation of, 90.
Tendo Achillis, tenotomy of, 70.
Tendon suturing, flexor biceps femoris,

72.
Tenotome, manipulation of, 67.
Tenotomy of adductor longus, 72.

of flexor carpi radialis, 69.
of flexor carpi ulnaris, 69.
of flexor biceps cubiti, 69.
of extensor communis digitorum, 69.
of flexor longus and brevis digito-
of flexor sublimis and profundus

digitorum, 68.
of extensor longus pedis digitorum,

70.
of flexor biceps femoris, 71.
of quadriceps extensor femoris, 71.
of longus hallucis, 69.
of peroneus longus and brevis, 70.
of flexor longus pollicis, 68.
of primi and secundi internodii pol-

licis, 69.
of semitendinosus and semimem.

branosus, 71.
of sterno-cleido-mastoid, 67.
of tendo Achillis, 70.
of tibialis anticus, 70.

of tibialis posticus, 70.
Thigh, amputation through, 143.
Thoracis, paracentesis, 11.
Thyroid artery, ligation of superior,

88.
Thyrotomy, 37.
Tibialis artery, ligation of anterior, 99.

anticus, tenotomy of, 70.
posterior artery, ligation of, 98.
posticus, tenotomy of, 70.

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