See Bell's Surgery, vol. vi. p. 411. White's Surgery, 199.

Amputation of the Hand.

Heister thinks it best to amputate the hand with a knife only, at the joint of the wrist; but the usual method is to cut through the bones above the wrist: in which case, see Amputation of the arm.

Amputation of the Metacarpal and Metatarsal Bones.

If any of these bones are carious, only so much as is disordered may be separated; a small spring saw is the most proper to divide the bones. After these opera-i ions, the parts heal soon, and a part of a hand or foot may still be useful.

In these cases carry your knife first, along the side of the bone that is to be removed, and as close to it as you can, at the same time making the wound as smooth as possible. If one of the middle bones is to be removed, we must of course make two incisions, one on each side: having done this, divide the integuments from the bone above and below transversely, then scrape off the periosteum, and saw through the bone with the saw called the metacarpal saw. Hold the saw very steady, and make long strokes when using it. If two bones are to be removed, we should proceed as above in general; also remember to divide the integuments, etc. transversely between the two bones, as is done between the tibia and fibula, or between the radius and ulna, in amputations of those parts. As in amputations of the fingers and toes, so in this case, the tourniquet is not required.

White's Surgery, 300.

Amputation of the Leg.

If the leg is to be amputated, though the injury is ever so near the ankle, as a long stump is thought more-inconvenient than a short one, it is preferred to amputate about four or five fingers' breadth below the tuberosity of the tibia; if it is cut higher, the aponeurotic expansion of the flexor muscle will be hurt; besides, the stump would be too short for an easy support on the wooden leg; and an artery which runs into the thickness of the tibia to be distributed to the marrow, would be unnecessarily wounded.

As the gastrocnemei muscles draw back the skin. more strongly than it is drawn elsewhere, it is proper, in order to keep the skin equal after the operation, to cut so that the wound on the calf of the leg is further from the middle of the ham, than the wound in the fore part is from the middle of the patella.

In amputating the upper limb and the breast, a chair is the properest to place the patient on; but for the lower limbs, a table about two feet and a half high is to be preferred.

The tourniquet must be placed three or four inches above the patella, and so as to press more particularly on the artery in the ham. The slips of plaster directed in the amputation for guiding the knife, must be placed four or five fingers' breadth below the patella; and the operator must stand on the inside of the leg, because the fibula will then be sawed at the same time with the tibia: but if, on the contrary, the saw is laid on the inside of the leg, the tibia will be first divided, and the fibula, being too weak to bear the force of the saw, will be apt to splinter, so not only render the operation tedious, but also the cure more difficult afterwards.

Though the practice of making a short stump hath so generally obtained, Mr. White prefers amputating betwixt the calf of the leg and the ankle, in cases that will admit of saving so much of the leg; he gives instances of his practice this way, and assures us, that the motion of the long stump is more easy than that of the short one.

After the separation of the limb, the dressing and general treatment will be the same as in amputation of the arm. See Medical Obs. and Inq. iv. 168. Bell's Surgery, vi. 374. White's Surgery, 204.

Amputation of the Penis.

If a cancer, or a sphacelus, in consequence of a scir-rhous gland, should appear in the penis, then every part to which the contagion had reached is speedily to be extirpated, lest the taint be diffused further.

Some cut off the penis with a knife; see Le Dran's

Operations: but the following method is to be preferred.

Pass a small tube of lead, or of silver, into the urethra, a little further than the affected part; then with a silken thread make a ligature upon the sound part near to that which is diseased; make this ligature tighter every day until the latter falls off. See Bell's Surgery, i. 538.

Amputation of the Thigh.

In this operation on the lower part of the thigh, the first incision is to be made a little more than two inches above the patella.

The tourniquet must press upon the crural artery, on the upper and inner part of the thigh, where the head of the vastus internus muscle and the triceps meet.

In amputating above the knee, we are advised to cut down to the bone at once; but as there is a great thickness of the skin and flesh, it is almost impossible. However, in cutting, we should remember that the stump should be of a conical form. In this case it is of no consequence on which side of the bone the operator stands. It frequently happens in amputating the thigh, that the flexor muscles contract more than the extensors; so that the patient's knee should be kept slightly bent while cutting through the latter, and extended during the incision of the former. This will produce a more convenient 6tump, without adding to the patient's pain. Perhaps it may be still better, according to Richter, to divide the extensors higher, and the flexors lower; or, which amounts to the same, in the relative positions just mentioned. Mr. Allanson recommends scooping out the flesh in the form of a truncated cone, but this greatly increases the pain without any adequate advantage; nor, according to Richter and Mursinna, is it easily or usefully practised. However the operation is performed, the skin that is preserved is brought together as nearly as its size will permit, and, as much as possible, joined by the adhesive inflammation.

When amputation is performed on this limb, the muscles, not being attached to the body of the bone, frequently retract; this never happens in the arm, and may be remedied by placing the patient on his side, and keeping the muscles in as relaxed a state as possible. The method of amputating with flaps was first invented to remedy this inconvenience, which hath occasioned the contrivance of a new mode of amputating, by Mr. Allanson, of Liverpool. He first makes an incision through the skin, then dissects a sufficient quantity of it from the muscles to cover the stump; divides the muscles down to the bone, where he finishes the dissection, and then saws through the bone at the same place, in the usual manner. He afterwards takes up the vessels with the tenaculum, brings the skin over the stump, leaves the ligature hanging out at the external orifice, and applies no kind of dressings except something to cover it superficially.

After the operation, the roller that is to keep down the skin should go round the waist, and descend down the thigh to the stump: thus abscesses are prevented, which otherwise would form themselves on the upper part of the thigh. It has been recommended in amputations of this limb, to dissect away the cellular substance, as this has been thought to produce all the suppuration and discharge: it hath been tried, indeed, and with seeming success: but others omit this part of the operation, and think the cellular membrane is a convenient cushion for the stump to rest on.

Another circumstance deserving attention is, after the operation, to press the crural artery the whole length of the thigh by a long bolster.

The operation has been sometimes performed with a double flap; that is, a portion of the skin is preserved from above and below. This mode of performing it has not yet become general; yet our experience hitherto is in its favour. One inconvenience attending the operation with one or two flaps is, the haemorrhage sometimes ensuing, which has induced Mr. Halloran to propose our not attempting the union till the suppuration has come on, both in the stump and the internal surface of the flap. They are then applied to each other with more advantage.

If the operation is made on the upper part of the thigh, the danger is very great; the discharge from the wound when it digests being so copious, that the patient's strength soon sinks, and death is a speedy consequence. If amputation in the upper part of the thigh be necessary, it would be best performed in the articulation; for then the crural artery would be better secured, and many other inconveniences avoided which attend in the usual method; but in the most desperate circumstances, taking off the thigh at the articulation is not yet encouraged. Bell's Surgery, vol. vi. 338. White's Surgery, 201.

This Herculean operation has been practised with, at least, promise of success, by Mr. Kerr of Northampton. (Duncan's Med. Com. vi. 33"); yet we suspect the danger must be very imminent to lead to a similar trial.

The boldness of modern surgeons has, however, gone one step further. Mr. Park has proposed, in cases where an accident, or a swelling of the joint of the knee or the elbow, rendered amputation necessary, to saw through the bones near the joint, on either side of the articulation, and unite the disjointed ends by a callus, as a stiff joint was preferable to the loss of a limb. He admits, that it may be of less use in scrofulous swellings than in cases of fracture near the joint. We have, however, no instance of a follower of this intrepid example; though we think the attempt much more justifiable than some others which we shall have occasion to record.

A German surgeon, M. Wrabetz, proposes amputating without the knife. A cord is to be macerated in a strong vesicating ointment; and, after retracting the skin, to be tightened round the limb. The crevice which it makes is to be filled with an astringent and antiseptic powder, and the patient supported with tonics and cordials. The cord must be kept constantly tight till it reaches the bone, which we suppose must be then sawn off, though this is not mentioned.

See Sharpe's Operation of Surgery, ch. xxxvii. Sharpe's Critical Enquiry, ch. vii. Heister's Surgery. Le Dran's Operations. Bilguer's Dissertation on Amputations. A Complete Treatise on the Gangrene and Sphacelus, with a new Method of Amputation, by Mr. Ohalloran. Allanson's Practical Observations on Amputation. Mynors's Practical Thoughts on Amputations, etc. London Med. Journal, vol. i. 231. Bell's Surgery, vol. vi. 301. White's Surgery, 190.