410 ON AMPUTATION 



would be diminished if the flap could be made shorter by not carrying the horns 

 of the incision by which it is formed so high up the limb ; and on making experi- 

 ments on the dead body several years ago, to ascertain to what extent this could 

 be done without disadvantage, I found that it is by no means difficult, when the 

 parts are in their natural condition, to accomplish the operation without making 

 any anterior flap at all, the integuments in front being divided transversely 

 at the level of the lower end of Mr. Garden's flap. I also found it advantageous 

 to form a short posterior skin-flap, both for the sake of coaptation of the cuta- 

 neous margins without puckering, and as a useful addition to the covering for 

 the end of the stump. 



With this modification, the operation is performed as follows. The surgeon 

 first cuts transversely across the front of the limb from side to side at the level 

 of the anterior tuberosity of the tibia, and joins the horns of this incision pos- 

 teriorly by carrying the knife at an angle of forty-five degrees to the axis of the 

 leg through the skin and fat. The limb being elevated, he dissects up the 

 posterior skin-flap, and then proceeds to raise the ring of integument as in a 

 circular operation, taking due care to avoid scoring the subcutaneous tissue ; 

 and, dividing the hamstrings as soon as they are exposed, and bending the knee, 

 he finds no difficulty in exposing the upper border of the patella. He then 

 sinks his knife through the insertion of the quadriceps extensor, and having 

 cleared the bone immediately above the articular cartilage and holding the limb 

 horizontal, he applies the saw vertically and at the same time transversely to 

 the axis of the limb (not of the bone), so as to ensure a horizontal surface for the 

 patient to rest on. The popliteal artery and vein are then secured, and any 

 articular or other small branches that may require it. 



When the soft parts are thickened and condensed by inflammation, the 

 integuments cannot well be reflected above the patella with such incisions of 

 the skin. But the difficulty may be got over by cutting into the joint as soon 

 as the ligamentum patellae is exposed, and at once removing the leg by dividing 

 the ligaments and hamstrings ; after which the soft parts can be retracted from 

 the femur sufficiently to permit the application of the saw. The arteries having 

 then been secured, the patella is dissected out at leisure. 



As thus performed. Garden's operation takes a little more time and pains 

 than when the integument is divided in the form of an anterior flap ; but these 

 are well rewarded by the ample covering for the bone, the small external wound, 

 and the perfect security against sloughing. 



Some surgeons speak highly of amputation through the knee, leaving the 

 articular portion of the femur and the patella, a covering being provided by 

 forming a large anterior and short posterior skin-flap from the leg, the result 



