The principal objection to the long dorsal rectangular flap (which makes an excellent covering) is, that unless it can be obtained from over the wrist-joint it requires the bones to be sawn so very high up. This may be avoided, to some extent, by making it shorter and rounded off, as in Carden's Amputation, _q.v._ AMPUTATION IN UPPER TWO-THIRDS.--Where the fore-arm is very fat or fleshy, this amputation can be very easily performed by two equal antero-posterior flaps made by transfixion. In most cases, however, from the comparative leanness of the dorsal aspect of the limb, the following method will have the best result. The surgeon must, as in the former case, shape a rounded dorsal flap by dissection from without (Plate IV. fig. 5), embracing the whole breadth of the limb down to the palmar edge of both bones. Then at once he transfixes the two points of this dorsal flap, and cuts out an equal one from the anterior aspect of the limb (Plate IV. fig. 6). Dissecting up the dorsal flap he clears the bones at least half an inch above as before, and applies the saw. _N.B._--This operation should be performed even in cases where only an inch of radius can be retained, as the attachment of the biceps makes a very small stump of fore-arm wonderfully useful. AMPUTATION AT ELBOW-JOINT.--In cases where it is found impossible to save any portion of the fore-arm, disarticulation at the elbow-joint may be easily performed. This operation was proposed and performed so long ago as the days of Ambrose Paré,[30] was much approved by Dupuytren, Baudens, and Velpeau, had fallen into disuse for a time, but is now again recommended by some excellent surgeons, especially by Gross[31] and Ashhurst,[32] both of Philadelphia. It is tolerably easy to perform, and does not involve any sawing of bones, but the flaps are apt to be cut too short, unless care be taken, from the manner in which the trochlea projects downwards beyond the line of the condyles, so that if the base of an ordinary-shaped flap be made on a level with the condyles, it will prove insufficient to cover the bone. It may be performed either by the circular method (Velpeau), oval (Baudens), or by a long anterior and short posterior flap (Textor and Dupuytren). Probably the best method is by a long anterior flap when it can be obtained, thus:--The arm being placed in a slightly flexed position, the surgeon transfixes in front of the joint, in a line extending from the level of the external condyle to a point one inch below the internal condyle (Plate IV. fig. 7); the tissue should be held well forward at the moment of transfixion. The flap should be at least two and a half inches deep at its apex, which must be rounded off. The two ends of this flap may then be united behind by a semilunar incision (Plate III. fig. 2), which will separate the radial attachments. The ulna must then be cleared, and the triceps divided at its insertion.