ON AMPUTATION 393 



In amputating at a joint, if the tissues are healthy, the division of the soft 

 parts completes the process, there being no need to take away the articular 

 cartilage, which is almost as favourably circumstanced for healing as vascular 

 structures. Thus, when a linger is removed at the metacarpo-phalangeal joint, 

 the whole wound may unite by first intention ; or if suppuration occurs, the 

 cartilage undergoes a change into granulations by a process so speedy as hardlv 

 to delay the cure. 



The saw, for dividing the bone in other cases, should be broad-bladed, 

 with a stout back, like the ' fine saw ' of the carpenter, and should have smaU 

 but well-set teeth. In applying the instrument, its heel being placed upon the 

 bone, previously cleared of soft parts by a circular sw^eep of the knife, it should 

 in the first instance be drawn with firm pressure towards the operator, so as to 

 make a groove which it will have no disposition to quit in the first forward 

 stroke. The bone is thus cut precisely at the place desired. 



The assistant who holds the limb must take care not to press it forcibly 

 upwards, otherwise the saw will become locked ; nor must he draw it down- 

 wards to any great degree, or the bone will break and splinter towards the last. 

 But the operator should always be so placed as to be able to control with his 

 left hand the part which he removes. Should any projecting portion be left, 

 it must be removed with a pair of bone-pliers, which ma}' be substituted entirely 

 for the saw^ when the bone is of very small size, as in the fingers. In using them, 

 the flat surface should always be directed towards the parts that are to be pre- 

 served, as the other sides of the w^edge-shaped blades crush the bone while they 

 divide it. 



The tenaculum, long universally employed for seizing the bleeding vessels 

 in order to tie them, has been superseded by the catch-forceps, which, like the 

 bone-pliers, w^ere introduced into surgical practice by the late ^Ir. Liston. Besides 

 being alwa\-s more convenient, they have the great advantage of making the 

 surgeon independent of an assistant in cases of emergency. The ligature should 

 be tightly and securely tied, by reversing in the second half of the knot the 

 relation that the ends of the thread had to one another in the former half, or, 

 in the language of sailors, by making a ' reef-knot'. The larger arteries should 

 be drawn a little way out of their sheaths, as the best means of avoiding nervous 

 trunks and other unnecessary tissue. The principal \-eins also should be tied ; 

 the dread of exciting phlebitis by such treatment having proved entireh' ground- 

 less. As regards smaller vessels, the old rule was to tie only such as furnished 

 a distinct pulsating stream. lUit as the catgut ligature with short-cut ends has 

 none of the inconveniences of the long threads of silk or flax formerl}' employed, 

 there is now no objection to t^ing mere oozing-points, liowe\'er numerous ; and 



LISTER 11 D (\ 



