ON AMPUTATION 385 



a great advantage, as providing a muscular cushion for the end of the stump. 

 But this opinion was shaken by further experience. The muscular part of the 

 covering, no longer discharging its normal physiological function, degenerates 

 and dwindles, while the integument tends to become thicker and firmer, so that 

 the ultimate results of the flap and circular operations present no material 

 difference. On the other hand, at the time of the performance of the operation, 

 the method by transfixion has the great disadvantage that the muscular element 

 in the flap is almost always redundant, and has to be tucked back to permit 

 the edges of the skin to be stitched together, the natural result being tension 

 and confinement of discharges and consequent inflammatory disturbance. 

 In the ver}^ case in which the flap operation was first employed, viz. in the 

 upper part of the leg, the muscular mass proved very inconvenient from its 

 redundancy when the calf was largely developed ; and even under more favourable 

 circumstances the heavy and contractile flap was apt to shift from its position 

 or to drag down the skin of the front of the leg, so as to stretch it on the cut 

 end of the tibia, and induce ulceration. Hence Mr. Liston himself, so earlv 

 as 1839, preferred in muscular subjects a short posterior flap and an anterior 

 one of the same length, composed of integument only ; ^ and in the latter period 

 of his practice he changed this for the following modification of the circular 

 operation, which was also suggested independently by Mr. Syme, and was used 

 by him for many years in all cases of amputation in this situation. The skin 

 and fat are divided by two crescentic incisions with the convexity downwards, 

 so as to form short antero-posterior flaps of the integument, which is then dis- 

 sected up considerably higher than their angle of union, after which the operation 

 is completed as in the ordinary circular method." This plan gives essentially 

 the same result as the circular mode, while the raising of the integument is 

 facilitated, and its edges can be accurately adapted to each other without any 

 of the puckering that occurred at the angles of the wound after the old operation ; 

 and experience shows that when the soft parts have been divided in this way 

 they are quite as favourably disposed for primary union as when cut more 

 smoothly in the form of flaps. 



In the lower part of the thigh also, the presence of the contractile element 

 in the flaps was found to be injurious by increasing the disposition to jnotrusion 

 of the bone, from the action of the powerful hamstring muscles, cut so far from 

 their origin at the pelvis. Mr. Syme accordingly adapted his modification of 

 the circular method to that situation ; ^ and I can testify to the sufticienc\- of 

 the covering which it aftorded. 



' Liston's Elements of Surgery, 2nd edit., j). 786. 



'■* Syme's Principles of Surgery, qtli cclil.. p. 168. * Ibid., p. 170. 



