386 ON AMPUTATION 



The longer time required for this operation than that by flap was rendered 

 a matter of no moment by the discovery of anaesthesia in surgery, in the year 

 1846.^ Independently of the relief from bodily and mental suffering procured 

 by this great event, it must be regarded as an era in the history of amputation, 

 of at least equal importance with the invention of the tourniquet ; because, 

 pain being abolished during the operation, as well as dangerous haemorrhage, 

 surgeons are now, in the great majority of cases, deprived of all excuse for sacri- 

 ficing anything, either in plan or execution, to mere rapidity of performance, 

 and are enabled to regard simply what will most promote the two great ultimate 

 objects in amputation — safety to life, and usefulness of the stump. 



With regard to the latter object, it was till lately an understood thing that 

 the end of the stump was not adapted for bearing any part of the weight of the 

 body. Being tender from the presence of the cicatrix, it was not allowed by 

 the instrument-makers to touch the artificial limb at all ; the apparatus being 

 applied partly to the sides of the stump, but chiefly to some bony prominence 

 resting on the upper edge of the socket — the tuberosity of the ischium when 

 the thigh is concerned, and in the leg the internal tuberosity of the tibia, the 

 head of the fibula, and especially the lower border of the patella. 



To this general rule, however, a striking exception was presented by the 

 amputation at the ankle devised by Mr. Syme, in which the bones are divided 

 just above the malleoli, where they present a broad surface for diffusing the 

 pressure over the integument of the heel turned up to cover them, specially fitted 

 by the character of its epidermic investment and subcutaneous fibro-adipose 

 cushion for bearing the weight of the bod}^ while the cicatrix lies well forward 

 out of reach of pressure. The result is that the patient can stand on the end 

 of the stump as on the natural sole ; and when the deficient spring of the arch 

 of the foot is compensated by some elastic material contained in a very simple 

 boot, the limb proves nearly as useful as in its normal condition. 



Subsequent experience has shown that similar advantages may be attained 

 to a greater or less degree in stumps formed by amputation higher up the limb. 

 It is easy by proper management to ensure the cicatrix falling out of reach of 

 compression by the end of the bone ; and the integument, though tender in the 

 first instance, gradually acquires a brawny and callous character when subjected 

 to regulated pressure, like the skin over the dorsal aspect of the cuboid bone 

 in talipes varus, and thus becomes able to bear the whole or part of the weight 

 of the body according to the breadth of the cut surface of the bone, and the 

 consequent diffusion of the pressure. Indeed, stumps possessing these qualities 

 were occasionally obtained as long ago as the time of Alanson, who, speaking 



^ See the essay ' On Anaesthetics ' (printed in vol. i, p. 135). 



