4o8 



ON AMPUTATION 



osseous membrane, and would be very liable to be punctured during the dissection 

 if we did not follow Mr. Teale's advice in conducting it. He pointed out that 

 in consequence of the looseness of the cellular connexions of the interosseous 

 membrane, there is no difficulty in separating the parts in front from its surface 

 with the finger-tip, while dividing with the knife the attachments of the muscles 

 to the bones.^ In this way, the vessel is secured from any chance of injury. 



Immediately above the ankle the operation is performed as follows. The 

 diameter of the limb having been ascertained by spanning it, a straight longi- 

 tudinal incision of that length is made at the inner side of the leg, and on the 

 outer aspect another similar incision directly over the fibula and extending 

 about an inch higher up. The lower ends of these incisions are connected by 

 cutting across the front of the limb in a direction transverse in the main, but 

 rounded off where it joins the lateral lines. The knife is next carried round 

 the back of the limb to the bones from the upper end of the internal incision 

 to a point exactly opposite on the outer side, which will be about an inch below 

 the upper end of the outer incision ; the instrument being carried in a line 

 slightly convex downwards, so as to form a very short posterior flap. The 

 anterior flap is then raised in the manner above mentioned, including every- 

 thing in front of the bones and interosseous membrane ; after which the tibia 

 and fibula are cleared as high as the level of the upper end of the outer incision, 

 the finger-tip being still used in detaching the parts anterior to the interosseous 

 membrane. 



In order to avoid splintering the fibula, it is best to saw both bones at the 

 same time, and to finish the fibula before the tibia. The sharp angle of the 

 spine of the tibia being apt to cause ulceration of the skin over it, should be 

 removed ; and the most convenient way of doing this is to commence with 

 sawing obliquely for a short distance from a point about half an inch above 

 the place where the bones are to be divided transversely. Supposing effectual 

 antiseptic treatment employed, the cutaneous margins of the flaps may be 

 stitched very closely, except at the upper end of the outer incision, which is 

 left open for the drain, and serves admirably for the purpose, as it leads directly 

 from the cut surfaces of the bones, and is dependent in position from the circum- 

 stance that the limb reposes on its outer side. Accurate stitching is desirable 

 elsewhere, in consequence of the disproportion of the sizes of the two flaps, 

 which, however, is diminished by making a short posterior flap as advised. 



In amputating through the calf on the same principle, the operation is 

 similar, except that, for reasons before discussed,^ the anterior flap need not 

 be longer than two-thirds of the diameter of the limb ; but, to compensate 



^ See Medical Times and Gazettejuly 6, 1861. * See p. 391. 



