398 ON AMPUTATION 



making the incision on the side next the thumb, to carry the knife from the 

 point of the knuckle in a longitudinal direction to near the level of the web 

 between the fingers, before sloping it off towards the palm, otherwise the flap 

 will be insufficient to cover the raw surface. A preferable method, however, 

 is to make dorsal and palmar flaps of rounded form, by cutting from the web 

 between the fingers to a point on the opposite side of the articulation at a suffi- 

 ciently high level to allow the end of the metacarpal bone to be taken off obliquely 

 with phers, so as to get rid of what would cause an unseemly prominence. But 

 if it be necessary to remove a considerable portion of the metacarpal bone, the 

 former method, with the dorsal part of the incision extended upwards, will be 

 the best. 



Similar rules apply to the little finger ; ^nd, in cases requiring it, the whole 

 metacarpal bone may be removed, by commencing the incision a little above 

 the articulation with the os unciforme, so as to give space for dividing the liga- 

 ments after clearing the bone of the muscles which surround it. 



Any portion of the thumb is valuable for opposition to the fingers ; but, if 

 necessary, the whole of it may be taken away by cutting in a curve, with the 

 convexity downwards, from the web connecting it with the forefinger to the 

 opposite side of the joint, both on the dorsal and palmar aspects, raising the 

 rounded flaps, and disarticulating. The whole metacarpal bone may be removed 

 along with the thumb on a similar plan, by entering the knife a little above 

 the articulation with the trapezium, and cutting first longitudinally, and then 

 with a gentle curve to the web, on each side of the bone, then dissecting up the 

 flaps, and dividing the ligaments of the joint. ^ This operation has been often 

 performed for tumour of the metacarpal bone ; but from a case published by 

 Mr. Syme, it would appear that under such circumstances a useful thumb may 

 be preserved by excising the bone affected.- 



The thumb alone or a single finger, being far more useful than any substitute 

 should always be retained if possible in cases of injury ; an artificial hand being 

 afterwards used, provided with a claw, against which the single digit left may be 

 pressed so as to hold objects firmly. 



Amputation at the wrist-joint may be performed by cutting across the back 

 of the wrist from one styloid process to the other, in a line presenting a slight 

 concavity downwards, in accordance with the form of the articulation, opening 

 the joint on its dorsal aspect, then shaping a rounded flap in the palm, raising 



^ For removing the thumb or Uttle finger with the metacarpal bone, other modes of operating, 

 somewhat more rapid, but in other respects disadvantageous even when apphcable, were recommended 

 before the introduction of anaesthesia. At present, it appears only necessary to mention such as are 

 calculated to give the best results. 



Observations in Clinical Surgery, p. 38. 



