402 ON AMPUTATION 



ing to the judgement of the operator. Even when a large raw surface is left, 

 the granulating process will complete the cure, as is well illustrated by some of 

 Larrey's cases, which terminated satisfactorily after extensive loss of the soft 

 parts of the shoulder and removal of portions of the scapula. 



Amputations in the Lower Extremity 

 The distal phalanx of the great toe may be removed in the same way as that 

 of a finger. When one of the smaller toes is in a condition requiring amputation 

 at all, it should be taken away entirely, since any portion left would be Hkely 

 to prove inconvenient from being tilted upwards. The operation is exactly 

 similar to that for a finger ; but it must be borne in mind that the articulation 

 with the metatarsal bone, which is the starting-point for the incisions, is much 

 further behind the web than the corresponding joint in the hand, in proportion 

 to the size of the digit. 



When the whole great toe is removed, or the little toe, the prominent part 

 of the head of the metatarsal bone must be cut off by an oblique application 

 of the bone-pliers, as it would prove inconvenient if left. The longitudinal 

 part of the incision in the soft parts should be placed on the dorsum of the foot, 

 to avoid the inconvenience that might arise from pressure on a scar at the lateral 

 aspect. In amputating the great or little toe, together with the whole meta- 

 tarsal bone, it is best to proceed as in the analogous operation for the little finger, 

 the incision being commenced on the dorsum of the foot, about a quarter of an 

 inch behind the articulation with the tarsus, and carried longitudinally to near 

 the metatarso-phalangeal joint, where it bifurcates to embrace the root of the 

 toe. The knife, which should be a strong one, is then applied with a short 

 sawing action close to the metatarsal bone and its articulation with the toe, so 

 as to clear them completely ; and the ligamentous attachments of the base of 

 the bone are lastly divided with the point of the instrument. In the case of 

 the great toe, it is especially important to keep the knife well under command, 

 and avoid thrusting its point deeply into the sole ; for this, besides inflicting 

 unnecessary punctures, may wound the plantar artery at a part difficult of 

 access. This mode of removing the great or little toe and its metatarsal bone, 

 though not so rapid as that of dissecting up a flap from the side of the foot, then 

 cutting between the toe to be removed and the adjoining one, and disarticulating, 

 has the great advantage of avoiding any scar in the sole. 



If more metatarsal bones than one require removal, the incision must be 

 begun in the same way, but made to include the roots of all the toes concerned, 

 so as to form a dorsal and a plantar flap ; and even in case of caries in the articu- 

 lation between the tarsus and metatarsus at one side, a useful foot may be left 



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