ox AMPUTATION 411 



being that the patient rests his weight upon the broad rounded end of the bone 

 while the patella is drawn up by the quadriceps to occupy the hollow between 

 the condyles in front. ^ There can hardly, I think, be two opinions as to the 

 superiority of Garden's method to this procedure for carious disease of the 

 knee-joint ; and in cases of injury, when the integuments are sound as far as 

 five inches below the patella, which is the length of the long anterior flap accord- 

 ing to the method hitherto recommended,- a satisfactory though very short 

 stump may be made below the knee. But from my experience with Garden's 

 operation I feel sure that the amputation through the knee may be much 

 improved by dividing the integument in the circular fashion, slightly modified 

 to permit neat adjustment of the cutaneous margins, in which case it would 

 not only be freed from the risk of partial sloughing of the anterior flap which is 

 admitted by its advocates,^ but, the posterior integument being made to take 

 a larger share in forming the covering, it would not be needful to go so far down 

 the limb in front, and thus the operation would become available for cases of 

 injury reaching too high in the limb to permit amputation below the knee. 

 And in order to ensure complete adequacy of the covering, the saw might be 

 carried through the middle of the articular end of the femur so as to flatten 

 it without interfering with its breadth, and thus in all probability improve 

 rather than impair the fitness of the end of the stump for bearing the weight 

 of the body. On this matter, however, I cannot as yet speak from personal 

 experience. 



In amputation of the thigh, if we except cases in which the soft parts are 

 affected at one side only, where a covering may be advantageously provided 

 from the sound side, the flaps should always be antero-posterior, because, the 

 flexor muscles being no longer counteracted b}' the weight of the limb, the bone 

 tends to become tilted forwards, so that its extremity would be apt to show 

 itself in the anterior angle of lateral flaps. 



In the lower half of the thigh, the method by longer anterior flap, on the 

 principles before considered,' will be found easy of execution and excellent in 

 results. Two straight incisions are made through the skin and fat along the 

 lateral aspects of the limb, parallel to its anterior surface, and equal in length 

 to two-thirds of its diameter, and their inferior extremities are connected in 

 front by a straight transverse cut, curved upwards near its ends to join the 

 longitudinal ones, so as to shape out a moderately long rectangular flap with 

 rounded angles, if we may so speak. The knife is then passed round the back 



* Sec especially a paper on Amputation at the Knee-joint, by Mr. Pollock, Mctiico-Chirurgiail 

 Transactions, 1870. 



* Sec Mr. Pollock, ibid. •■ Ibid. * See p. 3SS. 



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