On Amputation by a Long and a Short Rectangular Flap

THERE are few subjects in practical surgery on which opinion is more unsettled than on the best mode of performing amputation. If we refer to the works of British and foreign writers of the present century, we shall find the suffrages of the profession pretty equally divided between the circular mode of amputating, and the double-flap operation by transfixion.

In my early days of practice, upwards of thirty years ago, when fresh from the school of Lisfranc, I adopted the transfixion method by two lateral flaps. Charmed by the brilliancy of the operation, I expected it would prove equal to the utmost wishes of the surgeon. In the dissecting room it was certainly admirable, but when practised on the living body it did not equal my expectations, and soon gave way to the circular method. At a later period, the example and strong recommenda

tion of others led me to adopt the plan of transfixion, with an anterior and a posterior flap. This proceeding was also soon left off in favour of the circular incision, which I continued to practise until the middle of the year 1855, when the mode of operating was adopted which it is now my object to describe.

On reviewing my former practice and experience, if I were called upon to decide between the relative merits of the circular and transfixion methods, preference would be given to the former. My chief reasons for relinquishing these modes of operating are, the imperfect condition of stump generally resulting from them, and their great mortality.

In imputing generally imperfection of stump to the circular and double-flap transfixion methods, I shall perhaps be opposed by most surgeons who have amputated frequently. Each will be ready to say that he is in the habit of making excellent stumps, and indeed such was my own feeling in reference to these operations performed by myself. But, when the subject is considered more closely, we may ask ourselves, whether a stump is to be regarded perfect merely because it is of seemly form and not offensive to the sight. We ought further to inquire whether it is well adapted to locomotion, by being able to bear a considerable portion of the weight of the body on its end. As a general rule, it may be stated that the circular and transfixion stumps are not able to bear even the lightest pressure on their extremity. Being unwilling to rest this assertion on the personal experience of my colleagues and myself, I must appeal to the evidence which can be furnished by

surgical mechanicians who have had extensive experience in the adaptation of artificial limbs.

My acknowledgment is here especially due to Mr. Heather Bigg and Mr. Grossmith, for the prompt and unreserved communication of their own observations.

Mr. Bigg, in a letter which will be inserted in the Appendix, states that in his practice he does not allow any pressure to be made by the bottom of the socket upon the end of the stump, because the tenderness of the stump renders such pressure unbearable. The whole weight of the body is therefore thrown upon the upper part of the limb. Mr. Bigg has hardly ever found the cicatrix after amputation of the limbs, otherwise than adherent to the sawn end of the bone.

Mr. Grossmith says, that it is his rule never to allow pressure on the end of the stump, except in amputations at joints. His practice in this respect has been founded on the fact, that he never found the patient able to bear such pressure without pain. He does not remember any circular or transfixion stumps, in which there was a soft, moveable mass of tissues over the sawn end of the bone, and, as a general rule, he has found the cicatrix adherent to the bone. The cicatrix thus united has proved the most tender part of the stump. For Mr. Grossmith's letter, I beg to refer the reader to the Appendix.

Mr. Thomas Eagland, of Leeds, states, that his experience is in perfect accordance with that of Mr. Grossmith and Mr. Bigg, as far as regards the stumps formed by the old methods of circular incision and transfixion.

Livros