ON AMPUTATION 405 



haemorrhage by the pressure of the thumb and linger of an assistant, placed 

 respectively on the middle of the fore part of the limb and behind the tibia, 

 about two inches above the joint, so as to control the anterior and posterior 

 tibial arteries, or by an elastic tourniquet above the knee, and the foot being 

 held at right angles to the leg, the surgeon puts his left hand behind the heel, 

 with the finger and thumb on the places where tlie incisions are to commence 

 and terminate ; these being the tip of the external malleolus and the point exactly 

 opposite on the inner side, i.e. not at the tip of the internal malleolus, but con- 

 siderably below and behind it. With a knife, short and strong both in blade 

 and handle, he now cuts down to the bone across the sole, from one of these 

 points to the other, in a plane either vertical or sloping slightly towards the heel 

 when that part is unusually prominent ; and then, extending the foot, joins 

 the horns of this incision by another running as straight as possible across the 

 front of the ankle. He next dissects up the posterior flap from the os calcis, 

 keeping the edge of the knife close to the bone with the guidance of the left 

 thumb-nail, till the point of the calcaneum is fairly turned, when he proceeds 

 to open the joint in front, divides each lateral ligament with a stroke of the 

 knife applied between the malleolus and astragalus, and completes the removal 

 of the foot by severing the tendo Achillis. He then prepares the bones of the 

 leg for the application of the saw ; taking care, when cutting behind the tibia, 

 to keep close to its surface, from which the posterior tibial artery is separated 

 only by a little loose cellular tissue ; and lastly, he takes off the malleoli along 

 with a slice of the intervening part of the tibia, sawing exactl}' perpendicularly 

 to the axis of the limb — that is to say, directing the saw vertically and trans- 

 versely while the leg is kept horizontal. 



It is a common mistake to make the inner end of the incision at the internal 

 malleolus, instead of opposite the extremity of the outer one. This has two 

 bad effects : it renders the flap unsymmetrical, and, what is far worse, it makes 

 it unnecessarily long, and thus introduces an element of difliculty and risk 

 into an easy and safe operation. For when the incision is carried forwards 

 into the hollow of the foot, it becomes a most troublesome task to turn back 

 the integument over the prominence of the heel ; and the knife being thrust 

 the operator knows not where, the subcutaneous tissue containing the vessels 

 on which the skin depends for its nourishment is punctured and scored, and 

 perhaps the point of the instrument itself appears occasionally through the 

 skin itself, while the flap is subjected to violent wrenching in the effort to draw 

 it back over the bony projection. Under such a combination of unfavourable 

 circumstances, it is but natural that it should slough. 



On the other hand, when the flap has been made as above directed, in 



