ox AMPUTATION 387 



of the condition of a patient on whom he had performed amputation above 

 the ankle by posterior flap, says : ' He has been several voyages to sea, and 

 done his business with great activit}^ He bears the pressure of the machine 

 totally upon the end of the stump, and has not been troubled with the least 

 excoriation or soreness.' ^ But it is easy to understand why such results were 

 altogether exceptional so long as the covering for the ends of tlie bones was 

 provided by a posterior flap, which, from the force of gravity and the prepon- 

 derating power of the posterior muscles over those at the anterior aspect of the 

 limb, must alwa^'s tend to drop from its original position, and leave some part 

 of the bone to be covered only by cicatrix. And independently of this, in the 

 case of the leg, the tibia being covered in front merely by the skin, a scar placed 

 anteriorly is much more likely to suffer from pressure against the bone than one 

 situated posteriorty. The amputation of the ankle is, indeed, by posterior 

 flap ; but the full rounded cushion formed by the cup-shaped integument of 

 the heel renders this an entirely exceptional case. It is plain, therefore, that 

 with reference to fitness of the stump for bearing the weight of the body, prefer- 

 ence should be given to an anterior flap, which moreover has the great advantage 

 of allowing a dependent opening for the escape of discharge. 



The recognition of the advantages of the anterior flap is due to the labours of 

 two English surgeons, the late Mr. Teale, of Leeds, and Mr. Garden, of Worcester, 

 working independentty of each other, and proceeding by different methods. 

 Mr. Teale, who had the priority in publication, formed a long anterior and short 

 posterior flap in the following manner. Having ascertained by measurement 

 the semi-circumference of the limb where the bone was to be divided, he first 

 traced with pen and ink upon the skin four lines of that length ; two longitudinal, 

 extending downwards along the sides of the limb, and two transverse, of which 

 one joined in front the lower ends of the longitudinal lines, while the other ran 

 across behind from one longitudinal line to the other at the distance of a quarter 

 of their length from their upper extremities. Two rectangular flaps of very 

 unequal lengths being thus mapped out, he raised them, including the muscles 

 as well as the integuments, by cutting from without inwards, and sawed the 

 bone at their angle of union ; then, after tying the vessels, he bent the long 

 anterior flap upon itself, that it might ' form a kind of pouch for the end of the 

 bone', turning up its lower edge to meet that of the short posterior flap, to which 

 it was carefully adjusted and united by a few points of suture, some stitches 

 being also introduced where the edges of skin met at the sides of the stump. - 



Experience with this method has shown that in properly selected cases it 

 gives admirable results ; the patient being often able to rest his entire weight 



' Alanson, On Amputation, p. 133. * Tcalc, On Amputation, pp. 34 et seq. 



