412 



ON AMPUTATION 



of the thigh at an angle of forty-five degrees to its axis, marking out a short 

 posterior skin-flap, which is at once dissected up, the hmb being well elevated 

 by an assistant. The anterior flap is next raised so as to contain a moderate 

 amount of muscle, and the soft parts being well retracted, the knife is swept 

 circularly through the muscles, so as to expose the bone for the application 

 of the saw about two inches above the angle of union of the flaps. 



The incisions should always be made as far down in the limb as the state 

 of the soft parts permits ; and the skin over the patella, if available, will be 

 employed with great advantage as part of the anterior flap. 



For restraining haemorrhage the elastic tourniquet must be applied as 

 high as possible in the thigh, and if its constriction is found to interfere with 

 the due retraction of the soft parts, it is best 'to saw the bone in the first instance 

 where it is easily reached, and, after securing the vessels and removing the 

 tourniquet, expose the bone at the requisite level, and saw off an additional 

 portion, held steady with a pair of strong forceps. 



When digital compression is resorted to, the hands should grasp as much 

 of the circumference of the limb as possible, while the thumbs are placed one 

 above the other over the vessel, as it lies on the pelvis, midway between the 

 symphysis pubis and the iliac spine. 



Even in the upper part of the thigh, although the object of having a stump 

 capable of bearing weight upon its extremity is no longer to be considered, the 

 operation above described will be found to yield better results than that by 

 transfixion, by avoiding the redundancy of muscle which is the great defect 

 of the latter method. Nor need this plan involve greater loss of blood. For 

 the posterior flap, being only cutaneous, can be raised without material bleeding ; 

 and the anterior flap, after being shaped by carrying the knife through the skin 

 and fat, may be completed by transfixion, while comparatively little retraction 

 of the soft parts is required, in consequence of the short-cut muscles having 

 little tendency to cause protrusion of the bone. Moreover, all bleeding during the 

 performance of the operation may be effectually prevented by the elastic band 

 applied in the manner to be described in connexion with the next amputation. 



Amputation at the hip-joint has of late years been divested of much of 

 the danger that formerly attended it ; so that it now ranks among the well- 

 established operations of surgery. 



What may be termed the classical method is to form a large anterior flap 

 by transfixion, disarticulate, and cut a short posterior flap, also from within 

 outwards. The thigh being somewhat fixed, to relax the soft parts of the front 

 of the limb, the point of a knife with a blade fully a foot in length is entered 

 midway between the anterior-superior spinous process of the ilium and the 



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