Syme's amputation.

This issue of ARTIFICIAL LIMBS is, and always will be, a classical contribution to everything pertaining to Syme's amputation, including, as it does, the most detailed and accurate description extant of the proper method of doing the amputation. It has to be remembered that Syme was the greatest of the pre-Listerian surgeons and, indeed, his operation was developed to combat the disastrous septic complications that so often beset the surgeon who dealt with compound fractures, especially where the bone was divided, in contrast to cases that were disarticulated. The fear of sepsis was no longer a real one after Lister's discovery, but that there were other and great advantages in this operation is proved by the fact that Syme's operation is still recognised by competent surgeons as a method of choice in the suitable case. But there have been criticisms of the operation. Harris has stated the reasons for this difference of opinion. He believes that these lie in the method of the operation and in the after-treatment. Various imperfections of the end-results and the methods of their avoidance are described. Most of these can be avoided by a careful technique, and if this were generally practised there would be fewer complications about this excellent operation. Harris reminds us of an important feature of anatomy not generally recognised. This is the specialised form of elastic adipose tissue developed between the calcaneum and the plantar aponeurosis which is resistant to pressure. There are here pockets of fat enclosed by dense septa of fibrous tissue. These fibrous tissue strands are in the form of the letter "U," with the open end of the "U" pointing towards the calcaneum. If this concept is true, it is obvious why the dissection of the heel flap should be close to the calcaneum, because if these little loculi are opened, as will happen if the dissection is through the subcutaneous layer, the fat content is extruded and an important weightbearing mechanism rendered useless. All modifications, apart from Syme's own one, have detracted from the good qualities of the Syme stump and, indeed, have often ruined its weight-bearing qualities and brought the modified Syme's operation into disrepute. Kelham