O&P Library > Artificial Limbs > 1961, Vol 6, Num 1 > pp. 4 - 43

View as PDF with original layout

The History and Development of Syme's Amputation

R. I. Harris *

James Syme (1799-1870), the last and greatest of the pre-Listerian surgeons (Fig. 1.), was renowned in his day as the most eminent surgeon in the English-speaking world. Well informed and well trained by study and travel, he developed in practice the experience, courage, sagacity, and dexterity that enabled him to obtain improved results in the surgical treatment of disease at a time when anaesthesia and antisepsis were unknown. During his occupancy of the Chair of Clinical Surgery at the University of Edinburgh (1833-1869), he developed and perfected many new surgical procedures. Time has outmoded them all save one-his disarticulation amputation through the ankle joint with preservation of the heel flap to permit weight-bearing on the end of the stump.

In the days before antisepsis, the surgeon's efforts to cure his patients frequently ended in disaster. Compound fractures and operation wounds were almost invariably complicated by one or other of the "hospital diseases": erysipelas, septicaemia, pyaemia, hospital gangrene. The patient was fortunate if he escaped death. On rare occasions his wound might heal by "first intention" or "under a scab." Otherwise the wound became "inflamed." If it discharged "laudable pus," it might heal by "second intention," and if so the outlook was reasonably good. But if the discharge was "thin, watery, sanious, acrid," the future for the patient was ominous. Death too frequently supervened. We know now that these complications were the manifestation of virulent infections. But in 1843, when Syme wrote his first paper On Amputation at the Ankle Joint, Pasteur's work on fermentation which first revealed to us the world of microorganisms, was still more than a decade in the future (1856), and Lister, the founder of antiseptic surgery, was at age 16 finishing his preliminary education with a view toward entering University College, London. Twenty-four years were to elapse before Lister first wrote on his success in treating compound fractures with carbolic acid (1867). Till then the surgeon resigned himself, as had his predecessors from the dawn of history, to the possibility that his most skillful efforts and even the most simple of his operations would be followed too often by dangerous or even fatal reactions. Writing of this period, Volkmann said in flowery simile:

The surgeon is like the husbandman, who having sown his field, waits with resignation for what the harvest may bring, and reaps it, fully conscious of his own impotence against the elemental powers, which may pour down on him rain, hurricane and hail storm.

There is a vivid and moving picture of the surgery of the preanaesthetic and preanti-septic era in the story Rab and His Friends. The author, John Brown, was Syme's pupil and later his colleague and friend, and he admired him profoundly. In the memorial he wrote after Syme's death, he stated:

He was my master-my apprentice fee bought him his first carriage; a gig, and I got the first ride in it, and he was my friend. He was I believe the greatest surgeon Scotland ever produced; and I cannot conceive of a greater clinical teacher.

In the account of Ailie's operation, in Rab and His Friends, Syme is the surgeon, and John Brown is the house surgeon who tells the story. In spite of Syme's skill in removing Ailie's breast for cancer, she develops septicaemia and dies. The agony of her death from this frequent complication of the surgery of those days is so graphically depicted that it brings home to us with dramatic force the immense risks which beset the individual who sustained a compound fracture or was compelled to submit to surgical treatment-all the more impressive because it is told to us by a participant in the tragedy.

In the case of open fractures, the complications were so likely to be fatal that the most radical measures were deemed necessary to forestall the spread of "putrefaction." Immediate amputation through the thigh was the standard procedure for compound fractures of the tibia and fibula, amputation at the site of election (a hand's breadth below the tibial tubercle) for caries and compound injuries of the foot . Though the mortality from these amputations was 25 percent in the hands of the best surgeons and 50 percent in hospitals less carefully managed, the results were better than those to be had from any other form of treatment. The result of conservative treatment was much worse. Mortality from compound fractures of the femur so treated was 80 percent, from compound fractures of the tibia 50 percent, and from compound dislocation of the astragalus 87 percent. Whether patients were treated conservatively or by amputation, the mortality from compound injuries of the foot was shockingly great. Of those who survived compound dislocation of the astragalus without amputation, Syme said:

. . . the foot generally remains in such a state of stiffness, weakness and sensibility to external impressions as to be rather an encumbrance than a support to the patient.

For those who survived after amputation of the leg, the disability from loss of the limb also was great. In the words of Syme :

So long as the only alternatives were an attempt to preserve the limb and amputation of the leg, there was a strong inducement to abstain from operating. But if the patient's safety and speedy recovery may be ensured by taking away merely that part of the limb, which in the circumstances can be of little value either to use or ornament, while at the same time a stump is produced in all respects preferable to a shattered, stiff, irritable foot, I think there should be little hesitation in resorting to amputation at the ankle joint under the circumstances in question.

During a period of study in Europe (probably in 1822 in Paris, where he attended Lisfranc's course of surgical operations on human cadavers and Dupuytren's lectures and clinical demonstrations), Syme learned the technique of Chopart's amputation for removal of part of a foot damaged or diseased. He introduced the procedure in Edinburgh in 1829, and the results he obtained convinced him of its merit.

Chopart's amputation (disarticulation at the mid-tarsal joint, long plantar flap) was seldom complicated by the hospital diseases that made amputations through the leg so dangerous, and it left the patient with a partial foot capable of weight-bearing and with a movable ankle joint above it. We now know that the success of Chopart's amputation was a demonstration of the principle that, in the presence of sepsis, disarticulation is a much safer procedure than is amputation through muscle masses and the open medullary cavities of long bones. Articular cartilage left on the end of a bone, or the subarticular cortical plate and the network of cancellous bone deep to it, serve as barriers to the spread of infection, whereas the intermuscular and interfascial planes of an amputation stump provide easy pathways for invasion by microorganisms. Syme could not know the true reason for the life-saving merit of Chopart's amputation because knowledge of bacteria and of wound infections was still in the future. His conviction of its value was founded on empirical experience.

Syme commented upon the merits of Chopart's amputation as follows:

The operation of Chopart, which leaves only the astragalus and os calcis, is the most valuable of all partial amputations as it commands the largest portion of the foot requiring removal for disease or injury, and at the same time preserves a support for the patient not less useful than that which is afforded by the whole of the tarsus. Its introduction was long opposed on the ground that the extensor muscles of the ankle, acting through the tendo achillis, when no longer antagonized, would draw up the heel and point the cicatrix to the ground. I performed this operation in 1829, so far as I know for the first time in Edinburgh (Great Britain?) and have frequently done so since with the most satisfactory result, no inconvenience having been experienced from the source just mentioned, as the cut ends of the tendons on the forepart of the joint speedily acquired new attachments enabling them to counteract the extensive power.

Syme's favourable impression of the merit of Chopart's disarticulation at the mid-tarsal joint led him to apply the same principle to the ankle joint when caries or compound injury involved the astragalus or calcaneus, problems for which Chopart's amputation was inadequate. He performed his first disarticulation at the ankle joint in 1842, thirteen years after his first Chopart amputation. The long delay in applying to the ankle joint the principle which was so successful at the mid-tarsal joint arose from the problem of how to make the long stump bear weight satisfactorily. Disarticulation at the ankle joint might prove as effective as Chopart's amputation in saving the patient's life, but the long stump would prove an intolerable nuisance unless the patient could walk upon it. In Chopart's amputation, walking upon the stump presented no problem since the whole of the posterior half of the sole of the foot remained intact, and upon this the patient walked almost as easily as upon a normal foot. Amputation at a higher level (a hand's breadth below the tibial tubercle) permitted weight-bearing by applying the flexed knee to the padded cleft in the upper end of a crude prosthesis. This was "amputation at the site of election," a useful operation if the patient survived, but the mortality rate was 50 percent.

To make disarticulation at the ankle joint a functional success, some procedure was needed which would permit all the body weight to be borne upon the end of the stump in a manner similar to Chopart's stump. Other surgeons had attempted to solve this problem without success. Syme's solution was to detach from the underlying tarsal bones the whole thickness of the posterior half of the sole of the foot, disarticulate the astragalus from the mortise of the ankle joint, remove the malleoli, and then reapply the heel flap to the lower ends of the tibia and fibula. This proved to be the technique necessary for a satisfactory end-bearing stump at the level of the ankle joint for it provided a thick and bulky covering for the end of the stump composed of tissue adapted to weight-bearing.

Syme's account of the development of his new operation is interesting:

The idea of amputating at the ankle joint is not new, the operation having been performed on the Continent by different surgeons before I thought of it; and it would probably ere now have become generally adopted but for the doubt that was entertained as to the ends of the bones being sufficiently covered to afford the patient a comfortable and useful support for the limb. For my own part when I read of dissecting flaps of skin from the instep, or sides of the foot, I felt so much distrust in the protection that could thus be effected against the injurious effects of pressure on a part so exposed to it, that I had no desire to try the experiment. But it occurred to me, that by performing the operation in a different way all such objections might be obviated. This was to save a flap from the sole of the foot and the thick integuments of the heel, by making a transverse incision, and dissecting these parts from the os calcis, so that the dense structures provided by nature for supporting the weight of the body, might still be employed for the same purpose. Two trials of this operation having proved satisfactory, I communicated them to the profession, and am glad to find that not only my colleagues in the hospital here, but also practitioners in other planes have already acted upon this recommendation. The additional experience of my own practice now enables me to suggest some improvements in the mode of procedure-point out an error to be avoided [this was cutting the posterior tibial artery before division into the median and lateral plantar branches]-and verify the expectation formerly expressed as to amputation of the leg being hardly ever required.

Since Syme does not say why it took him so long to evolve this successful technique, we can only speculate upon the reasons. It may be that the principle of raising a skin flap and then replacing it in a new position was sufficiently radical to make him hesitate. This is a possibility for it was known that amputations with flaps were more prone to postoperative troubles than circular amputations. Or it may be that he was so immersed in the many other new surgical procedures he introduced that time elapsed before he gave thought to disarticulation at the ankle joint. Or it may be that it required thirteen years of experience with Chopart's amputation to convince him that disarticulation was so much more safe than amputation that he would be justified in applying the principle to the ankle joint. Probably this last supposition is important. In the era of "hospital diseases" it was of immense value to know that disarticulations could with certainty be relied upon to heal without the complications which after amputations endangered life and marred the healing of the stump.

Syme's first patient was a 16-year-old boy who suffered from caries of the tarsal bones, almost certainly tuberculosis. Syme described the problem, the operation, and the result in his first published paper on the subject:

John Wood, aged 16, was admitted to the Royal Infirmary on the 8th of September, 1842, suffering from disease of the foot which had suppurated and ulcerated in consequence of a twist he had given to it in walking about twelve months before. The instep was swollen and there were two openings discharging pus. A probe entered the sinuses freely into the substance of the tarsal bones, more particularly the astragalus and os calcis.... As the disease had extended beyond the limits of Chopart's amputation it would have been necessary in accordance with ordinary practice to remove the leg below the knee, but as the ankle joint seemed sound I resolved to perform a disarticulation there. With this in view, I cut across the instep in a curved direction with the convexity towards the toes, and then across the sole of the foot so that the incisions were nearly opposite one another. The flaps thus formed were next separated from their subjacent connexions which was easily effected except at the heel where the firmness of texture caused a little difficulty. The disarticulation being readily completed, the malleolar projections were removed by means of cutting pliers.

Although a small slough separated from the edge of the lower flap, in which a counter-opening had to be made for the drainage of matter, the patient recovered with little reaction and left the hospital in three months. Five months after the operation:

. . . the wounds were soundly healed, and any degree of pressure can be born by the stump which has a round form, well suited for the adaptation of a boot or artificial foot, and is strongly protected from external injury by its thick integument.

The success of his first case led Syme to the following conclusion:

It thus appears that compound dislocation of the astragalus and caries of this bone and the surrounding articular surfaces are the principal cases for amputation of the leg. This amputation can usually be superseded by amputation at the ankle joint. . . . The advantages promised by amputation at the ankle joint instead of operation near the knee are: 1st, That the risk to life will be smaller: 2nd, That a more comfortable stump will be afforded and 3rd, That the limb will be more seemly and useful for progressive motion. ... On these grounds I think amputation at the ankle joint may be advantageously introduced into the practice of surgery. I regret having cut off many limbs that might have been saved by it, and shall be glad if what has been said in its favour encourages others to its performance.

Between 1843 and 1846 Syme wrote four more papers on amputation at the ankle joint,and he reprinted them with a summary in Contributions to the Pathology and Practice of Surgery. Therein he states:

I have operated in more nearly two than one dozen of cases with perfect success.

Years later (1857) he wrote again to attest to the satisfactory results obtained by his amputation at the ankle joint. He had been aroused by a review in Lancet of the then new (4th) edition of Fergusson's System of Practical Surgery, in which appeared the following sentence: "Mr. Fergusson states, in relation to removal of the foot at the ankle joint in the manner recommended by Mr. Syme; that he had formed from experience a most unfavourable impression against it." Syme wrote to the editor of Lancet to refute Fergusson's statement. He said:

Sir,

Fifteen years ago I proposed a mode of affording relief from diseases that had been held to require amputation of the leg, by removal of the foot at the ankle-joint. This proposal was favourably received, and has long since been adopted by intelligent surgeons at home and abroad as the established procedure in cases proper for its performance. It is easily executed, and proves in the highest degree satisfactory, if done in accordance with certain principles which have been carefully explained, but is difficult and disastrous if performed incorrectly.

He then included letters from three patients upon whom he had performed his amputation at the ankle joint, respectively 10, 14, and 15 years earlier. One of them was his first case. All were well-with useful, painless stumps on which they could walk without difficulty and without a prosthesis if necessary.

Before Syme died in 1870, the problem of hospital diseases was in the process of solution as the result of the clinical studies of his son-in-law, Joseph Lister. Today, more than a century since Syme first wrote on amputation at the ankle joint, we have accumulated an immense fund of knowledge on the problem of infection in surgery, and we have at our command effective measures for its control. The technique of aseptic surgery and the rigid standards of cleanliness and hygiene in operating rooms and hospitals have to a large degree enabled us to eliminate infection from our surgical procedures. When infection does occur, we can now do more to control it with antiseptic and bacteriostatic and antibiotic agents than has ever before been possible. Today, therefore, the merit of Syme's amputation lies not chiefly in the circumstance that "the risk to life will be smaller." On the other hand, it still remains the most useful of all amputations of the lower extremity "because a more comfortable stump is provided, and the limb is more seemly and useful for support and progressive motion."

Of historical interest in demonstrating Syme's conviction of the merit of end-bearing stumps in the lower extremity is the record of his attempt to devise, at the level of the knee, an end-bearing stump embodying the principles which had proved so successful at the ankle. Two years after his first account on amputation at the ankle joint he reported the results of his attempt on two patients to remove the lower extremity at the knee and to close the wound with a skin flap so that weight could be borne on the end of the stump.Both patients seem to have been suffering from tuberculosis of the knee joint. In both, the femur was transected through the condyles just above the carious articular surface, and the end of the stump was covered with a long posterior flap of skin derived from the calf. Both wounds healed without complication, though they took a long time to do so.

It seems evident from Syme's presentation of these two cases that he was concerned chiefly with devising an operation safer than amputation through the shaft of the femur and that he believed that transection through cancellous bone just above the articular surface would involve less risk from hospital diseases than would amputation at a higher level. Since he did not cover the end of the stump with skin accustomed to weight-bearing, he evidently believed that the achievement of a healed stump without sepsis and without serious risk to the life of the patient was the prime objective and that good function and even end-bearing would follow good healing.

Twenty-one years later he wrote again about transcondylar amputation of the femur. His interest had been renewed by Carden's report of a method of amputating through the knee or through any part of the lower end of the femur using to cover the end of the bone a single, long, anterior flap composed of skin and subcutaneous tissue only. The muscles were divided at the level of transection of the bone and thus were excluded from the flap as was also the patella. Carden's purpose was to avoid the thin, sensitive, adherent cicatrix ("retreating muscles and obtrusive bone"), which so frequently resulted when equal flaps were used, and to cover the end of the femur with a broad cap of skin and subcutaneous tissue accustomed to bearing the weight of the body in kneeling (Fig. 2.). Syme warmly commended Carden's amputation, which he said could be performed with little risk to the patient and had the additional advantage that:

. . . the stump proved eminently serviceable since the skin over the bone, instead of becoming thinner, acquired additional thickness so that patients could rest upon it just as they do after amputation at the ankle.

In the same publication, Syme acknowledged that his earlier attempt to perfect the technique of transcondylar amputation had failed and that the method had fallen into disuse because the skin flap derived from the calf of the leg "proved very inconvenient." Syme, therefore, nearly achieved success in devising an end-bearing stump at the transcondylar level. He failed because his attention was focused upon the avoidance of sepsis and because he did not appreciate the importance of covering the end of the stump with skin naturally adapted to weight-bearing-a strange circumstance since he seems to have been well aware of the value of "the thick integuments of the heel" in the ankle-joint cases.

DEVELOPMENT OF SYME'S AMPUTATION

Shortly after Syme's first publication on amputation at the ankle joint, the operation began to be adopted in England and Scotland, generally with satisfactory results. In subsequent publications Syme stressed details of technique he had found essential for success (i.e., avoidance of damage to the posterior tibial artery, separation of the heel flap by dissection close to the calcaneus, drainage of the dead space, etc.). By 1846 he had perfected the technique of the operation, and from then on he accumulated experience in the application of the procedure to various problems. But he wrote nothing more on the operation except the letter to the editor of Lancet in 1857.

BAUDENS' TIBIOTARSAL AMPUTATION

On the Continent, and especially in France, there was less ready acceptance of Syme's amputation, partly because a somewhat similar amputation had been reported by Baudens (Fig. 3.) in 1842, a year before Syme's first publication. Described as a "tibiotarsal amputation," it involved a procedure in which the foot was removed by disarticulation at the ankle joint accompanied by removal of the malleoli and the posterior half of the inferior articular surface of the tibia by a single saw cut. The end of the stump was covered with a flap from the dorsum of the foot which included in its thickness all the structures from the skin to the tarsal bones and intertarsal ligaments (skin, subcutaneous tissue, tendons, nerves, and blood vessels). Baudens' concern was to secure good healing by a flap which would drape itself over the end of the stump as the patient lay supine in bed and when healed would provide a long stump on the end of which the patient could walk (Fig. 4., Fig. 5., and Fig. 6.). When reports of Syme's operation reached France, there was renewed appraisal of Baudens' cases, and the columns of Les Annates de Therapeutique for 1845-1847 contain several references to the problem. The following editorial comment is typical:

Our readers already know the tibiotarsal amputation of the foot which Doctor Baudens performed several years ago on a young soldier at the Gros-Caillou Hospital. We followed the patient in this hospital and then at the Val-de-Grace to which he had been transferred and we were happy one year later to see him walk well with the aid of an ordinary dancing shoe supported by two small metallic splints. This soldier took long walks without fatigue, went upstairs and went down slowly, danced and jumped with agility. His peg leg made him an excellent support and all without even a limp. We were extremely satisfied with this result in spite of the fact that one or two other patients who had had this operation performed upon them by Doctor Baudens had succumbed from gangrene of the flaps. Doctor Baudens' patient was admitted subsequently to l'Hotel des Invalides. Soon we found him again admitted to the Infirmary of the Hotel and for several months he has continued there. His stump has become excessively painful. The cicatrix has re-opened and has ulcerated at several points. Doctor Hutin, the surgeon-in-chief, has been obliged to open two small new abscesses which had formed in the tissue of the scar and it is probable that the underlying bones are affected. The patient complains of acute suffering and he demands with earnest insistence an amputation near the knee. M. Hutin will probably be obliged to come to that. This fact raises questions which demand an explanation. Let us first remark that the indifference with which our surgeons, civil and military, have received the remarkable memoir of M. Baudens is not a proof that the operation is without value for it has been practised in Edinburgh by M. Syme half a score of times with complete success. (We say indifference for the reason that no French surgeon to this day has himself performed or even recommended M. Baudens' valuable operation.) It is true, however, that M. Syme had generally operated only upon children and that he had published only the immediate results of the operation. Now the question is what are the remote effects (of the operation) since the scar in M. Baudens' patient was not inflamed or ulcerated and did not re-open for more than a year after the operation. It is all the more important, therefore, to know the actual state of M. Syme's patients for this knowledge could decide whether in the patient at Les Invalides, the evil in the scar derives from morbid constitutional conditions as we have presumed or to inherent conditions in the form of the flaps or in the stump. We should recall that in M. Baudens' operation the top of the ankle is sawed off after the disarticulation, while M. Syme preserved the ankle intact. Let us say finally that until new facts come to enlighten the above questions and in spite of the very great aversion the civil and military surgeons show to adopting the tibiotarsal amputation, we persist in believing it beneficial in most cases which we have from time to time indicated. Amputation at the wrist is satisfactory; why then hesitate to operate at the same level in the inferior member? We know the reasons of those who oppose. Time and new facts will be the best judges.

We should not terminate this article without stating that there prevails in military practice a sort of aversion for all those operations which one could perhaps call de luxe such as partial amputation of the foot, supramalleolar amputation, etc. For several reasons orders have been to adopt the same treatment for all cases. It is otherwise in civil hospitals. We have already discussed the diverse questions connected with these declarations.

This editorial was reproduced in the Monthly Journal of Medical Science, where it came to Syme's attention. Certain inaccuracies demanded correction, and there was the implication that perhaps Syme's results were not as good as they were said to be or that, if they were, the reason should be found so that Baudens' operation could be modified and made acceptable on its merits.

Syme therefore wrote to the editor of the Monthly Journal of Medical Science to clarify the points in confusion. The gist of his reply was as follows:

1. He had operated upon a considerable number of patients (more nearly two than one dozen of cases) with complete success.
2. Most of his patients were adults (not children as stated by the editor of Les Annates de Therapeutique).
3. In one case only did he leave the malleoli intact and that was the case of an infant five months of age with an erectile tumour of the foot.
4. His results were satisfactory, in evidence of which he quoted from letters received from his first three patients, each of whom stated that the stump was satisfactory and was scarcely any handicap.
5. His mode of performing the operation was to obtain a heel flap of sufficient length by cutting from the tip of one malleolus to the tip of the other. By this the risk of sloughing was lessened if not entirely prevented.

The fact is that there was an essential difference between Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint. Both surgeons were striving to devise, for treatment of disease of the foot beyond the scope of Chopart's amputation, an operation which would replace amputation below the knee. They desired to diminish the risks to the patient's life and to leave him with a long, well-covered, unscarred stump capable of total end-bearing. Both surgeons disarticulated the foot at the ankle and removed the malleoli, with or without a thin flake from the lower end of the tibia. The essential difference lay in the nature of the flap used to cover the end of the stump. Baudens used a long flap from the dorsum of the foot because it would drape itself naturally over the end of the stump while the patient lay supine in bed. It required the minimum of fixation and permitted free drainage in the immediate postoperative period. Syme used a plantar flap in order that he might cover the end of the stump with the thick integument of the heel.

Syme's amputation at the ankle joint proved superior to Baudens' tibiotarsal amputation even in the days before antisepsis. Today, with infection eliminated as an operative risk, Syme's operation has even more to recommend it as the best operation of the lower extremity.

In addition to Baudens' tibiotarsal amputation and Syme's amputation at the ankle joint, several other amputations of the foot in the region of the ankle were devised in the latter half of the nineteenth century with the purpose of avoiding the grave complications of amputation through the leg and to provide an end-bearing stump. Though none of these proved to have the value of Syme's amputation, they are of historic interest.

ROUX'S AMPUTATION

Roux's amputation (1845) was a supramalleolar amputation with a medial flap to cover the ends of the tibia and fibula (Fig. 7.). The tibia and fibula were divided transversely above the articular cartilage, and the medial flap included all the skin on the medial side of the foot as far forward as the talonavicular joint and as far inferior as the inner margin of the sole of the foot. The advantages claimed were that the flap had an assured blood supply from the posterior tibial artery and that a weight-bearing stump could be salvaged from a foot with a heel flap damaged too extensively to permit a formal Syme's amputation. The disadvantage proved to be the inadequacy of the flap, which was too thin to withstand the stresses of weight-bearing.

It is interesting to record that Roux came to recognize the superiority of Syme's amputation. In 1846, after performing his first disarticulation of the ankle joint by Syme's method, he said:

It appears to me that by this operation art modifies without changing the language of nature; in fact, the malleoli being removed, the lower extremity of the leg affords a base of support which transversely exceeds that of the os calcis.

GUYON'S AMPUTATION

Guyon's elliptical supramalleolar amputation with posterior flap (1868) was performed by a single elliptical incision which encircled the heel and the front of the ankle joint (Fig. 8.). Only a finger's breadth of skin from the plantar surface of the foot in front of the heel was retained. A flake of the os calcis was removed at the insertion of the tendo achillis and retained with the heel flap, and the tibia and fibula were transected above the articular surface of the tibia. The heel flap, with its flake from the posterior end of the os calcis, was applied to the cut surfaces of the tibia and fibula, and the skin margins were sutured. The weakness of Guyon's amputation lay in the inadequate heel flap, which did not stand up under the stress of weight-bearing, and the small tapered end of the stump, which provided too small an area of support.

pirogoff's amputation

In 1854, Pirogoff (Fig. 9.), the greatest Russian surgeon of his day, published the account of his new operation at the ankle joint, which he intended as an improvement upon Syme's amputation. In 1847, at the Clinic of Professor Chelius at Heidelberg, Pirogoff had seen two patients upon whom Syme's amputation had been performed, and he was impressed with the results. In 1848 and 1849 he performed Syme's amputation on four patients, all of whom died (one of pulmonary tuberculosis, one of scurvy, and two of sepsis, one of whom had gangrene of the heel flap). In a fifth case, an attempt to perform Syme's amputation failed because of gross damage to the heel flap incurred in separating it from the calcaneus. Nevertheless, Pirogoff, in his attempt to deal with compound injuries and caries of the astragalus and calcaneus by some method better than amputation below the knee, continued to use Syme's amputation at the ankle joint as well as Baudens' tibiotarsal amputation and Roux's supramalleolar amputation with a medial flap. From his experience he came to the following conclusions:

1. The most difficult part of Syme's amputation is the separation of the heel bone from the skin. Only with great care can the tightly adherent skin be separated without injuring the flap or making it too thin.
2. In Syme's operation, the skin over the tendo achillis forms the base of the flap and is much thinner than the apex of the flap. If care is not taken, it may be cut too thin and the flap may become gangrenous.
3. A considerable depression remains in the heel flap of Syme's amputation after the os calcis is shelled out. It may form a pocket for the collection of pus.
4. In the method of Baudens, the skin over the lower surface of the os calcis is removed. In this operation the creation of a foundation for the stump is not accomplished as it is in Syme's method, where the thick skin of the sole of the heel forms a sturdy covering.
5. In Roux's method, the formation of the posteromedial flap is certainly easier than in Syme's method. The base is wider, and necrosis occurs less often because the posterior tibial artery is cut below its division. However, the base of the flap is thinner than the summit. The depression in the flap is just as deep as in Syme's method, and, finally, the Achilles tendon is completely cut at its attachment to the os calcis as in the two previous cases.

In order to avoid these inconveniences, Pirogoff devised a new procedure (Fig. 10., Fig. 11., Fig. 12., and Fig. 13.). The skin incisions resembled those of Syme. The skin, soft tissues, and tendons were divided down to the bone, and the ankle joint was entered from in front by dividing the capsule anteriorly. The lateral ligaments were detached from the malleoli and the astragalus displaced downwards. The capsule was then opened posteriorly and the superior surface of the calcaneus exposed. A saw placed through the two vertical limbs of the plantar incision and across the superior surface of the calcaneus behind the body of the astragalus and in front of the tendo achillis divided the calcaneus obliquely from above downwards at the junction of the middle with the posterior third of that bone. The posterior third of the calcaneus and the tendo achillis retained their normal attachments and formed an integral part of the heel flap. The malleoli were divided at their base and removed level with the articular surface of the lower end of the tibia. The inferior articular surface of the tibia was not removed unless it was diseased. When the vessels had been ligated, the heel flap was turned up and secured to the margin of the anterior flap by two or three sutures.

The operation was ingenious and had certain merits. If the wound healed satisfactorily and the calcaneal fragment fused to the tibia, an end-bearing stump resulted, longer than a Syme's stump, so that no prosthesis was necessary to compensate for the shortening. The patient walked without much "dipping" (limp). Also the heel flap was firmly fixed in place by fusion of the calcaneal fragment to the tibia. But there were risks which could mar the success of the operation. If the calcaneal fragment failed to unite to the tibia, an unstable and painful stump end resulted. If the wound became infected, chronic osteomyelitis with persistently discharging sinuses was prone to establish itself in the calcaneal fragment or in the lower end of the tibia. Weight was borne ultimately upon the skin over the back of the heel, an area not as well suited to weight-bearing as is the plantar surface of the foot. For success, the calcaneus had to be free of disease and the heel flap not seriously damaged by trauma. In an age when the nature and management of infection was unknown, it was an operation technically difficult and uncertain in its results. Pirogoff's first three cases were all complicated by serious sepsis, and many months elapsed before they could walk on their stumps. Even then they still had discharging sinuses. Syme's operation was easier to perform and more certain of a good result, and these advantages still prevail.

SUBASTRAGALAR AMPUTATION

Subastragalar disarticulation was first mentioned by Velpeau in a single small paragraph in his New Elements of Operative Surgery. He stated that it had been proposed to him by des Lingerolles, who seems not to have been a surgeon. At the time Velpeau had not performed the operation. He merely mentioned it as a promising procedure in selected cases of disease or injury of the foot. Farabeuf perfected the operative technique and described it with excellent engravings in his Precis de Manuel Operatoire. He also discussed its merits and limitations. There is also a paper by Hutchinson, which contains a good description of the operation as well as a report upon the end result obtained in six cases. Five of his cases, operated upon by the technique described by Farabeuf, were gratifyingly successful, while the sixth, in which the flap was formed by a technique similar to that of Syme, was imperfect because the heel flap could not cover the head of the astragalus without undue tension.

Subastragalar amputation is of value in a limited number of cases, the best technique being that described by Farabeuf. A large internal and plantar flap extends to the outer margin of the heel and as far forward as the base of the fifth metatarsal Fig. 14.. The subastragalar and astragaloscaphoid joints are opened from the lateral side, and the heel is inverted until the medial side of the os calcis can be reached. The os calcis is then freed from the heel flap beginning at the medial surface and is removed with the foot. Care must be taken to avoid injury to the posterior tibial artery. The advantages over Syme's amputation, as stated by Hutchinson, are:

1. The stump is some 2 in. longer than a Syme's stump.
2. It gives a broader base of support.
3. The elasticity due to ankle movement is of marked advantage in walking.
4. The pad at the end of the stump is much thicker.
5. The arterial supply is better and runs less risk during the operation.
6. The artificial foot can be better fitted to the stump.

Hutchinson states that between 1891 and 1900 Syme's amputation was performed under antiseptic surgery on 27 patients at the London Hospital. The outcome: complete failure, 3 (one died); suppuration and sloughing of flap, 12; good result, 12. Several factors other than imperfection in technique (e.g., difficulty in sterilizing the skin of the heel flap, delay in operating because of patient's "obstinacy," operation in unpromising cases) contributed to the poor results. Even with the advantages of anaesthesia and antisepsis, the results at the London Hospital were inferior to those of Syme. In his meagre accounts of long-term results, Syme makes no mention of a fatality, and the functional results were good. For best results from Syme's amputation, the cases must be selected carefully, and the operation has to be timed wisely and performed skillfully.

In Hutchinson's paper also is an informative note, quoted from Clinton Dent, on the amputations in the South African War. The following is a summary:

Syme's amputation was performed in a small number of cases, but the resulting stumps were not entirely satisfactory. Damage of the foot from trauma is perhaps not as good an indication for Syme's amputation as is tuberculosis, because of damage to the skin. Sloughing of the flap sometimes occurred. Syme's amputation depends more than any other upon very careful attention to the details of the technique.... In Syme's amputation it is really impossible to depart from the lines laid down by Syme in the fashioning of the flaps. [It will be remembered that Syme emphasized this in almost the same words in his letter to the editor of Lancet already quoted.] There may be merit in the subastragalar amputation. English surgeons are too limited in their methods of operating upon the foot and have a good deal to learn from their French colleagues.

The variety of ankle amputations introduced in the latter half of the nineteenth century is an indication of a common purpose on the part of the surgeons of that era. They were attempting to replace the dangerous operation through the upper end of the tibia with the safer disarticulation at the ankle and at the same time to provide for the end of the stump a covering which would withstand the period of postoperative sepsis without undue damage and which could ultimately permit weight to be borne upon the end of the stump. When we recall that, in its early years, Syme's amputation was performed without the benefit of anaesthesia, it is not surprising that sometimes it was executed imperfectly. Time has proved that success in Syme's amputation is dependent upon precise adherence to a particular technique. Even in today's era of advanced surgery, it still is necessary, if we are to avoid imperfect results, to use a technique which differs in no essential detail from that used by Syme.

In Syme's day, the chief difficulty that hampered the general acceptance of his procedure was the frequent occurrence of necrosis of the heel flap, and we can appreciate from Hutchinson's account that it was still a problem even in 1900 with benefit of antiseptic surgery. According to Dent also, necrosis of the heel flap was a complication of Syme's amputation performed on soldiers in the South African War. The chief cause of necrosis of the heel flap was injury to the posterior tibial artery. Syme himself learned, in the hard school of experience, the necessity for preserving this vessel. His account is as follows:

In describing the operation, I have said that care must be taken to avoid cutting the posterior tibial artery before it divides into the plantar branches and I may now explain more particularly the ground on which this advice is founded.

Elizabeth Wilson, aged seven, was admitted on the 19th of February on account of disease in her left ankle. . . . The foot was much enlarged, stiff and shapeless; and two sinuses allowed a probe to pass into carious bone.

On the 21st I proceeded to amputate at the ankle joint, but finding that anchylosis had taken place between the articular surfaces, I exposed the extremities of the tibia and fibula, and sawed them through without previously removing the foot as usual. In tying the vessels, it appeared that the posterior tibial artery had been divided before its division into the plantar branches, so that one ligature sufficed in place of two.

The stump looked remarkably well and the result of the operation was expected to prove very favourable. It was, therefore, with much surprise, and no small disappointment, that in the course of a few days I saw the flap had sloughed through fully half its extent. Recovery was consequently delayed much beyond the ordinary period. . . .

I attributed the sloughing in this case to the undue pressure of the bandage; and having occasion soon afterwards to perform the operation on a patient in Minto House, intentionally divided the posterior tibial before its division, in order to obtain the same facility in tying the vessel as on the last occasion. To my surprise and concern, the flap again sloughed to the same extent as in the case just related, and as great attention had been paid to the dressing of the stump, I could not refer this effect to the cause formerly supposed. But as on both occasions the artery had been cut before its division, while in all other cases it had been left entire, and as the flap, being deprived of nourishment from most of its ordinary sources, must be supplied with blood only through the successive anastomoses of small vessels, I concluded that this deviation from usual practice had led to the mischief in question, and I resolved to avoid it for the future.

A further cause of poor result from Syme's amputation was damage inflicted on the skin over the heel while the flap was being separated from the calcaneus or while the tendo achillis was being detached from its insertion. Unless the plane of dissection hugged the calcaneus, and unless the dissection was performed with precision and delicacy, the skin was apt to be buttonholed. It was this problem especially that led Pirogoff to introduce his operation and Guyon to devise his elliptical supramalleolar amputation at the ankle joint. Syme's amputation, then and now, is an operation which must conform rigidly to an exact technique. If it is not performed properly when first attempted, many of its advantages will be lost irretrievably. It is interesting that the technique necessary for success is almost exactly that which Syme himself ultimately evolved. As we shall see later in the section on technique, the only addition of proven value is subperiosteal separation of the calcaneus from the heel flap. All other attempts at improvement have failed to achieve the success which follows the use of Syme's original technique.

The 1914-1918 war, with its innumerable casualties, renewed interest in amputations. One outcome was the publication of an English translation of the small volume, Artificial Limbs, written by the French surgeons Broca and Ducroquet. In discussing end-bearing stumps, this monograph makes no mention of Syme's amputation. It lists only supramalleolar amputation, disarticulation at the ankle joint, subastragaloid amputation, and osteoplastic amputation through the ankle joint. An editor's footnote with respect to supramalleolar amputation states, "In England, of course, this is always called a Syme's amputation." This statement is not strictly accurate since an important detail of Syme's amputation contributory to its success is the large area of support provided for the heel pad when the lower end of the tibia is left intact or virtually so. Syme's operation is not a supramalleolar amputation; it is a slightly modified disarticulation. French surgeons, particularly Farabeuf, were meticulous in distinguishing between disarticulations (in which group Syme's amputation was included) and amputations (e.g.,the supramalleolar operations of Roux and Guyon). It is true that Syme himself always referred to his operation as "amputation at the ankle joint," but in doing so he evidently used the term "amputation" in a general sense and not in the exact sense of Farabeuf. It is certain from Syme's description of his operations, and from the derivation of his operation from the disarticulation of Chopart, that Syme's operation was in fact disarticulation of the foot at the ankle joint with removal of the malleoli. Had Syme emphasized this as precisely as did Farabeuf, he might have prevented the innumerable supramalleolar Syme amputations which have been performed because of imperfect knowledge of Syme's technique or in the hope of obtaining an improved stump. These are the cases which have cast doubt on the value of Syme's operation, for the resulting stumps are functionally imperfect and may be complete failures.

E. C. Elmslie, who translated and edited the English edition of Broca and Ducroquet, formed a high opinion of Syme's amputation. In a footnote to the paragraph on low leg amputations allowing walking with end-bearing only, he says, after brief discussion of Pirogoff's amputation, subastragaloid amputation, and disarticulation at the ankle joint: "In fact, in this region there is Syme's amputation and a number of other far inferior amputations which should never be considered when a Syme amputation is possible." In 1924, in the section on amputations which he contributed to Carson's Modern Operative Surgery Elmslie states with reference to Syme's amputation:

When successful it yields an excellent stump which is capable of complete end bearing. It can be fitted with a simple and cheap stump boot known as an elephant boot. Upon such a boot a patient with a Syme's amputation can often walk ten or twelve miles. In fact, Syme's amputation is so satisfactory that it may be said that all other amputations of the foot at a lower level are obsolete except amputation of the toes or parts of the toes.

Despite the high regard in which he held Syme's amputation, Elmslie does not appear to have understood how essential for success is exact adherence to the precise details of Syme's technique. For reasons which probably were related to limbfitting problems, Elmslie felt it necessary to secure an improved Syme stump, and for that purpose he devised a modified Syme amputation which is described in his chapter on amputations in Carson's Modern Operative Surgery. It is the only procedure for Syme's amputation that is described and illustrated there. Syme's original technique is not mentioned. Elmslie does not state clearly why he felt it necessary to revise Syme's technique. However, he does state that the Syme stump was too long and the end too bulky. Almost certainly these represent criticisms by the limbfitters of Elmslie's day, who certainly had difficulties in designing, manufacturing, and fitting a satisfactory prosthesis for a Syme stump.

ELMSLIE'S MODIFIED SYME'S AMPUTATION

Elmslie's modified Syme's amputation differed from the classical Syme's amputation in three essential particulars:

1. The heel flap was smaller.
2. The dissection was carried out from the dorsal to the plantar surface.
3. The tibia and fibula were transected at a level well above the ankle joint.

Apparently the purpose of these changes was twofold: to provide a small, neat, tapered end to the stump and thus avoid the bulge in the prosthesis necessary to accommodate a bulbous-ended stump; and to accommodate more easily the ankle-joint mechanism by high transection of the tibia and fibula.

Elmslie was not the first person to advocate high transection of the tibia and fibula to facilitate the introduction of an ankle joint mechanism in the artificial limb for a Syme amputation in the space between the end of the stump and the level of the ground. Henry Thompson, at a meeting of the Pathological Society of London on April 21, 1863, shared in the presentation of seven patients with Syme's amputation and two patients with Pirogoff's amputation. As reported in Lancet, Thompson's remarks were as follows:

He [Thompson] would not enter upon the various points of comparison between Syme's amputation and that modification of it in which a portion of the os calcis is left in the flap, but would only refer to the different results which remained after the two operations [i.e., Syme and Pirogoff] as regards the kind of artificial limb which is applicable afterwards. He thought it very important for the surgeon and the mechanician to act in concert in most amputations of the lower extremity and he therefore showed also two artificial limbs to illustrate the advantage in relation to this matter which the proceeding of Syme offered over that of Pirogoff. In the former the patient enjoyed the advantage of complete ankle joint movement of the limb; while in the other, the stump being so close to the ground, there was no room for it and the best substitute that could be applied was by iron hinges outside of the limb. . . . Mr. Thompson wished to point out the necessity of taking off a sufficient slice of bone, including the two malleoli instead of merely removing the lower portion of the latter, so as to avoid extreme width and a bulbous stump which was more difficult to fit with a well made artificial limb than a stump which tapered gradually from the calf downwards. . . . Mr. Thompson said that the objection to the bulbous form of the stump did not materially apply if the common circular shoe which is laced around the lower part of the leg was worn [elephant boot], but it did to the artificial leg.

In Elmslie's operation the skin incision was an ellipse (Fig. 15.) which commenced on the plantar surface of the foot 3/4 in. in front of the point of the heel. Therefrom it extended obliquely upward and forward over either malleolus to a point on the anterior surface of the ankle 1 in. above the joint line. The ankle joint was entered, the foot depressed, and the medial and lateral ligaments of the joint divided from within the joint. The astragalus was then dislocated from the mortise of the ankle joint by depressing the foot still farther. Doing so exposed the tendo achillis, which was then divided at its insertion. The calcaneus was then separated from the heel flap by dissection close to the bone from above downward. The tibia and fibula were transected 3/4 in. to 1 in. above the highest level of the ankle joint, and the heel flap was then closed over the ends of the tibia and fibula.

Though Elmslie intended his modified Syme's amputation to be an improvement over Syme's original procedure, the result has not lived up to his expectations, and for three reasons: the small heel flap deprived the stump of an adequate covering of skin and subcutaneous tissue adapted to weight-bearing; the high transection of the tibia and fibula diminished the cross-sectional area of their cut surfaces and impaired their support for weight-bearing; the end of the stump was no longer bulbous but was tapered, a feature that permitted the artificial limb to slip up and down during walking. He succeeded in simplifying the limbfitters' problem, and he succeeded in making the stump neat and tidy, but in so doing he sacrificed the qualities of Syme's amputation essential for success- namely, a bulbous stump end to ensure that the grasp of the prosthesis would be secure and a wide area of bony support covered by a large, thick, heel pad adapted to weight-bearing.

Elmslie's modified Syme's amputation thus closely resembled Guyon's elliptical supramalleolar operation with posterior flap. It seems probable that in modifying Syme's operation Elmslie adopted Guyon's technique, for the only difference between Guyon's elliptical supramalleolar amputation and Elmslie's modified Syme's amputation was that in the former, unlike the latter, a flake from the posterior end of the calcaneus was removed along with the insertion of the tendo achillis and that later the flake was applied to the cut surface of the tibia when the heel flap was sutured into place. Elmslie's modified Syme's amputation was widely used in England (but not in Scotland) during the period following the 1914-1918 war, probably because of the confidence with which he advanced it as an improvement over Syme's technique and probably also because he made no mention of Syme's technique. It is likely that this adoption of his modified Syme amputation in England led to the dissatisfaction with Syme's amputation expressed by Langdale-Kelham and Perkins of Queen Mary's Hospital at Roehampton. They said ". . . this type of operation does not stand weight bearing on the average longer than eight years. ... It is to be hoped that the modified Syme's amputation will soon be as obsolete as the original Syme's." The handbook of the British Ministry of Pensions, Artificial Limbs and their Relation to Amputations also speaks with faint praise of Syme's amputation. In Scotland, in contrast to England, a rigid adherence to the precise details of Syme's original technique resulted in satisfactory end-bearing stumps. In Canada, for a similar reason, experience has also been satisfactory. The favorable results with Syme's amputation in Scotland and Canada as contrasted with the dissatisfaction with Syme's amputation in England is evidence that a wide area of bony support covered by a large, thick, heel pad is essential for a satisfactory Syme's stump. Syme's original operation provided these indispensable features, and consequently his stumps bore weight on the end satisfactorily and more or less indefinitely. Attempts to improve upon Syme's amputation (e.g., the modifications of Roux and of Elmslie), chiefly in the matters of making the end of the stump neat and of providing the limbmaker with more space for the ankle joint of the prosthesis, proved unsatisfactory in the long run because the area of support was too small and because the covering over the end of the stump would not stand up under long-continued end-bearing.

Syme was blessed by good fortune as well as good sense. His sound judgment brought him to the conclusion that disarticulation at the ankle joint and removal of the malleoli would constitute a safe and effective means for the removal of a damaged or carious foot. The idea of preserving the heel flap to cover the end of the stump and to provide end-bearing could have come only from profound insight. His courage, boldness, and skill enabled him to devise a simple technique by which these things could be accomplished. It was his good fortune that the operation he planned and the technique he devised have both proved to be of continuing value. He knew nothing of the minutiae which concern us today, and he ill understood the grave complications which often discounted the surgeon's efforts. But he was far-sighted enough and bold enough to embark upon a radically new approach to an old problem, to build upon his first successes, and to eliminate such defects as were present in his first efforts (e.g., to preserve the integrity of the posterior tibial artery).

FUNDAMENTAL PRINCIPLES OF END-BEARING AMPUTATIONS OF THE LOWER EXTREMITY

The essential functions of the normal lower extremity are weight-bearing and locomotion, and amputation stumps in the lower extremity must be designed accordingly. The more perfectly they bear the body weight and transmit the forces of locomotion the more efficiently will they utilize prosthetic appliances. For purposes of weight-bearing, nothing is as satisfactory as a stump which can bear weight upon its end. Propulsion is best accomplished by a leg stump of the greatest possible residual length and with as many normally functioning nerves, muscles, and joints as can be preserved. Only two levels in the lower extremity can be adapted to provide end-bearing stumps-the lower end of the femur with a covering of prepatellar skin, and the expanded lower ends of the tibia and fibula covered by the heel pad.

To secure an end-bearing stump in lowerextremity amputations, certain requirements must be met:

1. In order to provide a broad area of support, the bone must be divided where its cross-sectional area is as great as possible.
2. The whole of the cut surface of the bone must be capable of bearing weight. This requirement can be achieved by a strong meshwork of cancellous bone across the whole area, or, in the case of the ankle joint, by retention of the subarticular cortical bone at the lower end of the tibia. The tubular cross-section of the shaft of the tibia at higher levels is unsuited to weight-bearing.
3. The skin and subcutaneous tissue covering the end of the stump must be appropriate for weight-bearing.
4. The weight-bearing skin must be properly centered upon the area of support and firmly attached to it.
5. The end of the stump must be bulbous, thus ensuring that the prosthesis will not slide off the stump or rotate upon it.

Syme's operation, properly performed, meets all these requirements. For conditions which require amputation in the vicinity of the ankle joint, it provides a stump superior to all others. But the initial operation provides the sole opportunity for securing a Syme stump satisfactory in all respects. Even minor deviations from detail are prone to result in a stump imperfect in one way or another, and such imperfections usually cannot be corrected by secondary operations. If the imperfection is not great, the stump may function reasonably well, for some time at any rate, but it may not stand up indefinitely, as has proved to be the case with Elmslie's modified Syme's amputation.

Because preservation of the unique structure of the heel pad is essential for attaining a perfect Syme stump, it is appropriate now to describe its specialized nature. In the human heel, as in other parts of the body adapted to weight-bearing (finger tips, thenar and hypothenar eminences, ischial tuberosities, and prepatellar pads), the ability to withstand the stresses imposed by the weight of the body and by body movements derives in part fro