. Manual of operative surgery. o the bone, as in circular amputation, 3 to 4inches below the axilla. Secure the vessels. Make a longitudinal incision alongthe outer and posterior aspect of the limb at right angles to the circular the bone. This method is capable of many modifications and may becarried out after arthrotomy has shown that the limb cannot be saved. Thesame may be said of Spences operation. In operations for malignant disease in the aged or in the presence of pro- AMPUTATION SHOULDER I l6l found depression or shock, Crile blocks the nerve trunks and operates underregion
. Manual of operative surgery. o the bone, as in circular amputation, 3 to 4inches below the axilla. Secure the vessels. Make a longitudinal incision alongthe outer and posterior aspect of the limb at right angles to the circular the bone. This method is capable of many modifications and may becarried out after arthrotomy has shown that the limb cannot be saved. Thesame may be said of Spences operation. In operations for malignant disease in the aged or in the presence of pro- AMPUTATION SHOULDER I l6l found depression or shock, Crile blocks the nerve trunks and operates underregional anesthesia. Criles Method in Shoulder Disarticulation (Problems Relating to SurgicalOperations, Crile, 1901J: Step I.—Under infiltration with Yiq per cent, cocaine solution. Make anincision along the outer margin of the sternomastoid just above the the deep fascia. Step 2.—Retract the omo-hyoid downwards, the anterior margin of thetrapezius backwards, the posterior margin of the scalenus anticus forwards. Fig. 1436.—Criles disarticulation of shoulder. {Crile.) (Fig. 1436). This exposes the trunks of the brachial plexus and by extendingthe dissection a trifle downwards the arching subclavian artery is seen. Whendissecting look out for small nerve twigs in the connective tissue planes oraccompanying blood-vessels. Anesthetize such nerves before dividing them. Step 3.—Inject each nerve trunk with just sufl5cient cocaine solution (^-^ percent.) to cause a localized swelling. The injection is made first into the outercovering, then into the substance of the trunk. This blocking causes complete loss of sensation and motion in the partssupplied by the brachial plexus. Step 4.—Apply Criles clamp with blades protected by rubber tubing, to thesubclavian artery. Step 5.—Amputate by one or other of the methods described. Note thatcuts on the outer and posterior aspects over the deltoid should be made lowdown to avoid skin supplied by the cervical plexus. Il62
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