ON AMPUTATION 389 



above that level, the bones would have to be divided an inch higher ; and a 

 difference of three-quarters of an inch in the skin would involve a loss of two 

 inches of the bones ; and, again, an affection of the integuments implicating 

 less than two inches above the tip of the malleolus would require a division of 

 the bones full four inches above Teale's seat of election. And in the last-named 

 situation, where the calf is thickest, the very long flap, consisting in the greater 

 part of its breadth of skin alone, would be very liable to suffer from sloughing. 



From considerations like these some of the stanchest advocates of Mr. 

 Teale's method are now disposed to restrict it to the lower part of the leg and just 

 above the knee, where, by turning to account the integument over the patella, 

 which is not used in ordinary operations, the anterior flap may be made of the 

 requisite length without specially high division of the bone. 



Mr. Garden proceeded upon a much more simple plan, forming a rounded 

 anterior flap of integument only, without any posterior flap, and retracting 

 the soft parts somewhat from the bone before dividing it with the saw ; ' thus 

 forming a flat-faced stump with a bonnet of integument to fall over it.'^ This 

 practice he began as early as 1846, nine years before Mr. Teale first employed 

 his rectangular operation ; and though refraining from publication, he obtained 

 from that time forward most admirable results, both in safety to life and the 

 amount of pressure that could be borne by the end of the stump. 



It was principally at the knee, where amputation had not previously been 

 much practised, that Mr. Garden applied his principle. The operation at 

 this situation is thus described by him. ' The operator, standing on the right 

 side of the limb, seizes it between his left forefinger and thumb at the spots 

 selected for the base of the flap, and enters the point of the knife close to his 

 finger, bringing it round through skin and fat below the patella to the spot pressed 

 by his thumb ; then turning the edge downwards at a right angle with the line 

 of the hmb, he passes it through to the spot where it first entered, cutting out- 

 wards through everything behind the bone. The flap is then reflected, and the 

 remainder of the soft parts divided straight down to the bone : the muscles are 

 then slightly cleared upwards and the saw is applied ' through the bases of 

 the condyles. ' Or the flap may be reflected first, and the knee examined, 

 particularly if the operator be undetermined between resection and amputation. 

 In amputating through the condjdes, the patella is drawn down by flexing the 

 knee to a right angle before dividing the soft parts in front of the bone : or if 

 that be inconvenient, the patella may be reflected downwards.' - 



This operation, wlien contrasted with amputation in ihc lower tliirtl of the 



■ Sec On Amputation by Suig/c Flap. By Richard Cardcii, i'.K.C.S., vS:c., p. 0. This is a reprint 

 of an article in the British Medical Journal, April 1S64. " Op. cit., p. 6. 



