272 OPERATIONS ON BONES. 



which has two bones, though they may be divided separately, it 

 will be preferable, if they can be held together with sufficient 

 firmness, to act upon them jointly, but finishing the smaller bone 

 first. 



The actual disarticiilation, or second step of the amputation, 

 is performed by dimiing the ligaments or other structures which 

 surround the joint, from without inward. Beginning with the 

 strongest and most external ligament by giving a movement of 

 semi-flexion to the articulation, not necessarily cutting them in 

 their middle, the joint is penetrated by inserting the knife be 

 tween the articular surfaces. The double sage knife, according to 

 Bouley, is the most convenient. In articidations composed of ir- 

 regular surfaces, united by inter-articular ligaments, care must be 

 taken to avoid injuring the bones, and to divide the fibrous cords 

 only, as most of the synovial capsules must be removed, in order 

 to avoid fistulous compHcations. 



In some disarticulations, according to Bouley, it is necessary 

 to use the saw to remove diarthodial projections on the surface of 

 the amputated bone, which if left in place would prove a serious 

 obstruction to the cicatrization of the stump 



The last step of the operation is the arrest, or, what is better, 

 the^:>ret'e?i^io?i of the hemorrhage. It consists simply in twisting 

 or ligating the arterial vessels which have been divided. If the 

 means used for the temporary hemostasis prevent the operator 

 from discovering its source, the ligatures can be slightly relaxed 

 until it is betrayed by the oozing of the blood. The various 

 methods of permanent hemostasis have already been considered, 

 and need no further description. 



In the application of a dressing to the wound of amputation, 

 the requu-ements are few, but they are imj)erative, and they are 

 sufficient, assuring the best results by theii' simphcity and solid- 

 ity. The soft tissues and the skin must be brought together, 

 over the extremity of the bone, and kept together by the aj)plica- 

 tion of a continued suture, lea\Tng a place of drainage for the 

 suppuration and the sloughing of the ligatures which occlude the 

 blood vessels, and the extremities of these must be gathered to- 

 gether at the most dependent part of the wound. This is com- 

 pleted and protected by the application of an antiseptic dressing 

 consisting of pads of oakum, absorbent cotton, or threads of 

 tourbe, kept in place by rollers, and supported by an outside 



