I 



ON AMPUTATION 397 



vascular supply and superior vital power. Thus, it is a more serious thinjs: to 

 amputate a toe than a finger, and to take away the arm at the shoulder-joint 

 is a much safer proceeding than to cut off a leg below the knee, even though a 

 larger wound be inflicted, and a larger portion of the body removed, in the former 

 case than in the latter. The more advanced in life the patient is, the more do 

 these differences show themselves. But if circumstances admit of the septic 

 element being effectually excluded, such considerations have comparatively 

 little of the weight formerly attached to them. 



The particular amputations in the upper extremity will be most convenientlv 

 considered in the order in which they occur from below upwards. The distal 

 phalanges, though very liable to injury and disease, rarely require amputation ; 

 for the removal of crushed portions of bone in the former case, or exfoliation in 

 the latter, will generally leave a useful end to the finger. If it be wished, the 

 phalanx may be readily taken away by opening the joint across its dorsal aspect, 

 and, after getting the knife round the base of the bone, forming a palmar flap, 

 by cutting from within outwards. Or the palmar flap may be first cut hv 

 transfixion ; and this being held up by an assistant, the operation is completed 

 by cutting straight through the articulation. If the whole distal phalanx be 

 crushed, amputation through the second phalanx will be best performed by 

 cutting from without inwards two rounded lateral or antero-posterior flaps, 

 and dividing the bone with pliers. 



Removal of the entire finger is generally preferable to leaving the first phalanx 

 by itself, which, besides being unseemly, would be a mere incumbrance, except 

 in the index-finger ; and even there it is of service only in some few handicrafts. 

 For the middle, or the ring-finger, the operation is best performed according 

 to the following definite rule. The adjoining fingers being held aside by an 

 assistant, the surgeon cuts from the prominence of the knuckle in a straight 

 line towards the middle of the web on one side ; but, just before reaching the 

 web, carries the knife inwards to the fold between the finger and the palm, and, 

 after making a similar incision on the other side, accomplishes the disarticulation. 

 The edges of the skin will be found to meet exactly on approximation of the 

 adjoining fingers, which should be kept tied in that position, to avoid disturbing 

 the process of union. Remarkabl}^ little deformity results from this operation, 

 so that removal of the head of the metacarpal bone for the sake of appearance 

 is quite uncalled for. If, however, it is at any time necessary on other grounds 

 to take away a portion of the metacarpal bone, this can be readily done by the 

 same method, except that the incisions are made to start from the place on the 

 back of tlie hand where the bone is to be divided by the cutting-pliers. 



Tlic index-finger mav b(^ rcmovt^l in a similar manner, care being taken, in 



