4o6 ON AMPUTATION 



accordance with the latest recommendations of the author of the operation/ 

 it applies itself with perfect uniformity to the surface it is designed to cover, 

 and has no disposition to shift to one side in the after progress of the case ; and 

 every stroke of the knife by which it is raised being made under the eye of the 

 surgeon, without any forcible traction, it is as little liable to slough as any other 

 portion of integument with an equally broad base and an equally rich vascular 

 supply. Even the integrity of the posterior tibial artery, though desirable, 

 is by no means essential, provided the rest of the subcutaneous tissue has been 

 left uninjured. Many persons, in discussing the merits of this operation, seem 

 to assume as an axiom that sloughing of the flap must occasionally take place ; 

 but I am persuaded from very extensive experience that, if the skin of the heel 

 be sound, such an occurrence will always be the fault of the surgeon. 



Hence the various modifications of the original method that have been 

 suggested, though commonly discussed chiefly with reference to a fear of slough- 

 ing, must be judged of entirely on other grounds. Thus the plan introduced 

 by the late Dr. Richard Mackenzie, of Edinburgh, of making the base of the 

 flap at the inner side, that it may have a more free supply of blood from the 

 posterior tibial artery, is not to be regarded as a substitute for the simpler method 

 of a posterior flap ; yet it proves useful in case of unsoundness of the integu- 

 ment on the outer side of the heel ; and it is probable that an external flap might 

 be made with equal advantage if the internal aspect of the limb were affected. 

 At the same time it may be worth while to remark that the mere presence of 

 sinuses at either side is no ground for deviating from the original procedure ; 

 and, further, that no degree of complication of sinuous tracks ought to induce 

 the surgeon to amputate in the leg and deprive his patient of the greatly superior 

 stump afforded by Mr. Syme's amputation. 



The operation of the late Professor Pirogoff, of Petersburg, in which the 

 posterior part of the os calcis is sawn off and turned up as part of the flap, to 

 unite with the cut end of the tibia, has the disadvantage in cases of caries that 

 it entails a risk of recurrence of disease in the portion of the calcaneum remaining. 

 It is also more complicated than Mr. Syme's method, from the necessity of 

 accurate adjustment of the osseous surfaces, with a view to the best position 

 for the posterior flap. For this purpose both bones are cut obliquely ; the 

 tibia in a plane looking somewhat backwards as well as downwards, and the 

 OS calcis in one that is directed somewhat upwards as well as forwards ; so that 

 when the cut surfaces are applied to each other, the dense plantar integument 

 covering the lower part of the calcaneum is presented downwards for supporting 

 the weight of the body, rather than the thin skin over the posterior aspect 



^ See Mr. Syme's Clinical Lectures in the Lancet, 1854. 



