ON AMPUTATION 409 



for its diminution, the posterior flap must be made at least half as long as the 

 anterior, by carrying the knife round the back of the limb at an angle of forty- 

 five degrees through the integuments, and dissecting them up to the level of 

 the upper end of the inner part of the incision, before cutting towards the bones, 

 so as to get rid of the heavy and contractile mass of the sural muscles. 



The old flaj) operation is still emplo^'ed in the calf by many surgeons, being 

 very readily accomplished by drawing the knife in a segment of a circle across 

 the front of the leg from one bone to the other, transfixing behind them, and 

 cutting first downwards and then gradually outwards, next dissecting up the 

 anterior flap of integument, and clearing and dividing the bones at the level 

 of its base. But it is, as we have seen,^ a most undesirable proceeding, on account 

 of the bulk of the muscular mass from the calf turned up to cover the ends of 

 the bones. Mr. Spence met this objection by shaving off a considerable portion 

 from the face of the posterior flap after forming it. But though this was 

 undoubtedly a great improvement, it could not give to the operation the advan- 

 tages of the method by longer anterior flap. 



When there is not enough sound integument to admit of the latter method, 

 the modified circular operation of Mr. Syme- proves highly valuable, enabling 

 us to form out of the smallest amount of materials a short stump, which is 

 preferable to any that can result from operating higher up in the limb, the 

 patient either retaining the use of the joint or resting his weight with great 

 security and comfort upon the bent knee. 



The great merits of Mr. Garden's amputation through the condyles of the 

 femur have been already fully discussed.^ I cannot but agree with him that the 

 patella should always be removed. In cases of injury it may seem a tempting 

 thing to leave it, sawing off its articular surface, that it may unite with the 

 divided end of the femur ; but having tried this plan before Mr. Garden published, 

 I have found that while it may result in an admirable stump, it is sometimes 

 attended with serious inconvenience, from the patella being tilted up from 

 its proper position by the action of the quadriceps extensor. Besides this, 

 the presence of the patella interferes with the adequacy of the covering for 

 the end of the femur, and makes it needful to borrow more integument from 

 the front of the leg than is otherwise requisite. And as regards the ultimate 

 result, when the sawn extremity of the femur has been rounded off by ossific 

 deposit, it proves Httle, if at all, inferior to the patella for bearing the weight 

 of the body. The only objection to Garden's operation, as described by him,^ 

 is the occasional occurrence of more or less sloughing of the long anterior flaj) 

 of skin, in spite of faultless operating. It is plain that the risk of sloughing 

 » See p. 385. » Ibid. ' See p. 38;. * Ibid. 



LISTER II E e 



