However, it would certainly tend on the whole to the saving of life to operate as soon as possible, not only in all those cases in which the necessity for it was evident, but also in all doubtful cases; as although a few limbs might thus be sacrificed, I have not the least doubt but that many lives would be qui avait ('to ope're' le premier et peu d'instans apres le coup, est le seul que ait ete' Larrey, vol. iii. p. 378. In fact, there can be little doubt but that it would tend greatly to the preservation of life in an army on active service, if it were made imperative on surgeons to operate in certain contingencies, in place of leaving it, as at present, to the discretion of each what cases to preserve and what to operate on; as the undoubted tendency among surgeons notwithstanding the Tl ilbrded a most excellent Held for tin- relative value of flap and circular amputa: as, although in our army the former was commonly 'veil, most ot' tlir Freneh and not a few of our own surgeons adhered bo
Hell termed a the peril of the operation.,f Amputation." As the advanal. of removing the limb as far as possible trunk is fully reeogm/i-d, it seems curious that ireular nn-de of operating, which I think admits of.in the operation hy flaps, should not be 1. In the lower part of the thigh this is Vularly observed. Protrusion of bone, is the g whieh terrifies most henee tlu-y make unnecessarily long flaps, and n move a much la. judice which so long exi-ted t<> the contrary is to amputate too little on the field of battle. I know full well such a could not bt> mail.. nor would it be withstood by a medical staff; but judged < tf bearing on results, I have little doubt but that it be successful.
As was said when speaking of coinpounl fractun>s and joints, every succeeding generation of surgeons go through, to a great extent, the same ordeal in gaining their experience. Tln-y th.-ir advanced attainmento encourage an atti-mpt whi.-h tli.-ir pn-d-i-.-s feared, and thus a vaat number of lives are ever being sacriii.! t<. tin- of indi vidual experienoe. Were it possible that a commission, a chi< t, an a.adcm y. or any competent body having authority, were to lay down in-t ructions at the beginning of a campaign binding on the surgeons of an array, with rrftrencr to points fully established by a lory ient induction, as well as those which called for their little dont.t hut that a large proportion.,f lives would In- saved during each war, and a mass of reliable facts added to our knowledge.
The tin, matin-t.it.of our knowledge Upon those Cases youd doubt, m arrangement as that <> of being a hinderance t- the advance uouhl, in trutli. roiuot,it. amount of the bone than is at all necessary. This very apparent in many amputations in the Syme has laid down the true principle which should regulate our proceedings, when he says, " It is not the length of the flaps which prevents the risk of protrusion of the bone, but the height at which it is divided above the angle of union of the flaps." In soldiers, as in many (although not all) cases submitted to primary amputation for accident at home, the proportion of muscle to skin and subcutaneous fat is different from what it is in most cases operated on in civil thus modifies our appreciation to some extent of the two modes of operating.
In soldiers there is commonly but little subcutaneous fat, and the muscles are large and strong; hence it becomes very difficult, when practising the flap operation, to adapt the parts to one another, so as to fulfil the latter part of the old maxim, " Muscle must cover bone, and integument muscle." It cannot be said that this arose in the East from the maladroit performance of the operation by the flap, as the same circumstance may be seen to occur at home in the hands of our ablest hospital surgeons. The paring and stuffing-in processes which are not uncommonly seen in hospitals, to correct the results of the condition referred to, are no less prejudicial than unsightly. The irritation is thereby increased, and proper adhesion of the parts prevented.