ON AMPUTATION 407 



of the bone. If these points are attended to, Pirogoff's amputation gives a 

 thoroughly useful stump in cases of injur\\ But I am not aware that it has 

 any advantages over that provided by Syme's operation, and the increased 

 length of the stump which it produces is rather objectionable than otherwise ; 

 for with the original operation, the space afforded for the artificial foot is not 

 more than the maker finds convenient. 



When the ankle-joint is affected with caries, the saw should be applied 

 at a higher level than usual to the tibia and fibula, and the vertical articular 

 surfaces by which the joint is continued upwards between those bones should 

 be removed with cutting pliers, to guard against recurrence of disease in that 

 situation. 



In cases which do not admit of Mr. Syme's operation, amputation imme- 

 diately above the ankle should be performed if possible, in preference to that 

 at 'the seat of election', a little below the knee; for, although the use of the 

 knee-joint may be retained even with a very short stump, the longer one gives 

 greater command over the artificial limb, and the operation involves less risk 

 to life. 



Different methods may here be emplo\^ed. One mode is to make a short 

 semilunar anterior flap cut from without inwards, and a large posterior one 

 formed by transfixing behind the bones and cutting downwards and outwards, 

 the saw being applied a little above the bases of the flaps ; or antero-posterior 

 skin flaps of equal length may be made, and the bones divided somewhat higher 

 up. Or again, the modified circular operation ^ is applicable in this situation. 



But the method by longer anterior flap is greatly to be preferred to any 

 other, on account of the excellent covering it affords, with the cicatrix out of 

 the way of pressure, enabling the stump to sustain the whole or a considerable 

 part of the weight of the body on its extremity. The principles on which the 

 operation should be performed have been already fully discussed in former 

 pages,- but a modification of the plan there indicated is called for on account 

 of the difficulty of retracting the soft parts from the bones. This arises especially 

 from the intimate attachment of the muscles to the fibula ; but if these are 

 divided through an extension upwards of the outer longitudinal incision, no 

 difficulty is experienced, unless the tissues are condensed by inflammatory 

 thickening, in effecting retraction of the remaining soft parts from the tibia 

 without dividing the skin at the inner side to a higher level than the tx-jiical 

 operation demands. Another point requiring special attention in the leg, 

 as compared with the thigh, is the raising of the anterior fla}-!. The anterior 

 tibial artery, on which the flap depends for its nutrition, lies close to the inter- 



' See p. 3cS5. • See pp. ^Sy et scq. 



