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Show 285 anruiarron AT ran snowman-J01". AMPUTATION AT THE SHOULDER-JOINT. 1. The patient is supported on a chair: an assistant stands behind him, and with some such instrument as a boot-hook, There is no occasion to cut or scarify the cartilage of the glenoid cavity; the flaps heal over it. on the iron of which there is bound a firm compress, he presses After what has been said of adhesive straps, and compress, down upon the subclavian artery, as it passes over the first rib. On this compression, however, the surgeon must not entirely there need be no further description. I am confident that it would be more easy to lay the flaps nicely together ; to unite them by long adhesive straps ; to apply soft compresses; to lay them in contact; and to secure the whole by the roller round the body and shoulder, in the form of the spica bandage-than to describe all this with precision. rely ; but taking what assistance he can obtain, he resolves at the same time to be independent of it. 2. Another assistant stands before the patient; he pushes his lingers into the axilla, and grasps betwixt his finger and - ' ~w0/‘mu u/ rennin, "Pi :r O x -k¥ 7 289 thumb the cord of the nerves and artery. This is not to compress the artery for the purpose of stemming the blood, but to facilitate an after part of the operation. 3. The surgeon, with his operating assistant, stands by the side or the assistant. His only instrument is a large scalpel of the common form. "he first incision is carried from the point of the acromion process, in a semicircular direction (convexly forward), to near the assistant's fingers, who holds the artery in the axilla. \‘ow the larger muscular arteries must be tied. (t. The second incision is a counterpart to the first, and is made in a semicircular direction, terminating by cutting through the tendon of the pectoral muscle, where the large branches are to be secured. 5. Now the surgeon cuts into the capsule, and cuts the lone: tendon of the biceps, when the assistant pushes out the head of the arm-bone from the socket. 6. He now carries his knife close by the lower side of the arm-bone; and then the assistant, who held the axillary 3-1"tery betwixt his finger and thumb, thrusts it up, and pi‘C- sents it. to him conveniently to be taken up with the needle, having first slightly detached it from the neighbour ing "'ii‘l‘VCS; and, lastly, Cutting across the remaining skin, the gzpei‘zrti011 is finished. "' hopptntd '1 1 . . . . ‘. It haS that then nrrvcs have hung from tne - ~ I ' 0., u by c,‘ . ' v ..: . . i , wound, naming, adhesion to the. eicatrix, have produce ed great, distress. The nerves are therefore to be cut .25 high x , , , ,. ' , he, and thrus t ccep into the wound. GENERAL CONCLUDING REMARKS. .HEMOBRHAGY, after amputation, may be the effect of insecure tying,r of the principal artery; and then it will be very terrible indeed. The surgeon will sometimes be conscious that from the faintness of the patient during the operation, he has been obliged to dress the stump without securing all the arteries of the second class. He has, perhaps, got only one or two secured, when in general amputation at the same part requires five or six branches to be secured. With the reviving strength, the arteries bleed, and the dressings have to be taken oil", and the face of the stump has again to be laid open ! It may happen that the integuments do not adhere to the face of the stump, the flesh hangs loose, and the arteries, from want of due inflammatory action, are insecure. Or it may happen that the stump opening, and becoming deeply ulcerat- ed, the arteries are opened, and bleed profusely. Bleeding from this cause may even happen in the third week. (See the Introduction.) The history of the operation, shows us that the elTect of the single incision in which the knife was carried down to the bone at once, was the pyramidal stump. Ravaton said that few escaped by that operation without the bone projecting. There were generally three or four exfoliations; and often the surgeon had to cut oli‘ the bone at the distance of some months. To the student the excellence of the London hospi- . 1"" 3 2 Y r V/UNl M09577! |