ON AMPUTATION 399 



it to the joint, and disarticulating. Another method is to cut the palmar flap 

 from within outwards after disarticulation ; but the prominence of the pisiform 

 bone prevents this from being satisfactorily accomplished. 



Amputation in the forearm may be performed by antero-posterior flaps. In 

 front, where the muscles are in larger amount, transfixion may be adopted ; 

 but behind, the presence of the two bones prevents this, except near the wrist, 

 where it may be effected, provided the soft parts have their natural laxity, by 

 pinching up the skin, and passing the knife as close to the radius and ulna as 

 possible, when, after the integument has fallen back to its usual position, the 

 extremities of the wound will be placed so far forward that the knife can be 

 introduced through them in forming the anterior flap. But it is probably always 

 well to cut the dorsal flap from without inwards, and to raise it so that it shall 

 consist chiefly of integument, in order that redundancy of muscle and consequent 

 tension may be avoided. The surgeon standing on the (patient's) left side of 

 the limb, and holding it with the dorsal surface towards him, enters the knife 

 a little to the palmar side of the bone that is the further from him, and cuts 

 through the skin and fat so as to shape a rounded dorsal flap, terminating the 

 incision a little to the palmar side of the nearer bone, where he at once pushes 

 in the point of the knife, so that it may pass in front of the bones and emerge 

 at the place where the operation was commenced, and cuts a fleshy palmar flap 

 from within outwards. He then dissects up the dorsal flap ; and the soft parts 

 being drawn back by an assistant, clears both bones thoroughly about three- 

 quarters of an inch higher up, and applies the saw. The interosseous arter^^ 

 which is apt to retract beside the unyielding interosseous membrane, must always 

 be secured as well as the radial and ulnar trunks ; and if the median or ulnar 

 nerve is exposed in the palmar flap, it should be shortened with scissors, to prevent 

 the occurrence of painful symptoms as the stump heals. 



There is no objection to amputation at the elbow-joint, in cases adapted 

 for it. The most eligible plan is to cut a large anterior flap from within outwards, 

 after transfixing the partially extended limb in front of the joint, bearing in 

 mind that the line of the articulation is oblique to the axis of the humerus, and 

 is considerably further below the internal than the external condyle. The flap 

 being then held up by an assistant, the points of transfixion are connected 

 posteriorly by a semicircular stroke of the knife, which, besides dividing the 

 integument, probably detaches the radius, and a few touches with the point 

 of the instrument will sever the connexions of the ulna. The assistant should 

 keep the skin of the back of the arm drawn upwards during the operation. 



Amputation of the arm presents a good example of the doublc-flaji operation 

 by transfixion. The point of the knife being entered at one side ol the limb, 



