AMPUTATIONS

AT a time like the present the subject of amputations comes up for discussion with great frequency amongst surgeons. In "Modern Methods of Amputation" Professor Vasconceloshas provided a clear and interestingaccountof many aspectsof the subject. The book is not of a convenient size for army surgeonswhose libraries are usually portable, but this is compensatedfor by the clarity of print and the ready understandingof the excellent diagrams. There is an introductory survey of "The Developmentof Amputation" by Norman T. Kirk, Surgeon-Generalof the United StatesArmy. This should be read by all young war surgeons. It gives an excellentperspectiveof amputationsin relation to their historical development. There is some irrelevant material, but the review is clear, instructive and well balanced. We sometimesforget the lessonslearnedby surgeons, often centuries ago, in the hard school of experienceand rediscover thesewith Ill-merited pride. For example, before antisepticsand anrestheticswere known It was agreedby surgeonsthat flaps should not be sewn when they were performing amputations on the field of battle. Mortality was higher when the flaps were sewn, deathbeing due to sepsisand secondaryhremorrhage. Amputationsare divided Into "closed" and "open" amputations,the former being performed with sewn flaps and the second 'being synonomouswith the guillotine amputation. One cannot agreewith this. The value of amputationwith unsewn flaps has been proven during this war provided that the dressing is so arrangedthat, to all intentsand purposes,the amputation is a completelyopenone. Of course,when this book was publishedthe place of penicillin had alreadybeen recognized in the treatmentof battle casualties, There Is no mention of this, since the book is, in effect, an "official report submitted by the authorat the Third Brazilian and'American Surgical Congress,which met in Rio de Janiero,November,1941". It is noted with surprise that the writer refers to "personal experience of some 1,500 primary amputations, repair of guillotine stumps and re-amputations". In passing, the Incision which we usually call a "racquet" or "raquette" incision is spokenof as a "ratchet". As one reads the Introductory history, one Is Impressed with the outstanding achievements, both as to manual dexterity and judgement,of Laney. Not only could he perform two hundred amputationsin twenty-four hours, but his views as to the type and time of amputationswere excellent In the light of the surgical knowledgeof his day. Professor Vasconcelos has written a book of value especially for repatriation and civil surgeons. It is disappointing that no referenceis made to conditions as seen In forward areas, which, after all, are the places where knowledge and judgementin regard to amputationsare of paramount importance. All proceduresdescribed in this book refer to casesIn which no sepsisis present,and, even so, in the chapter of general technique, there Is too much mention of suturing. While amputationsshould be done carefully and not roughly, as is frequently suggested,the careful suturing to the degreerecommendedis unnecessary, if not unwise. In this same chapter it would have been advisable to describe amputations performed without a tourniquet, which is necessaryin some circumstances. The discussion of levels of amputationsis excellent and hasa distinctly practical flavour, However, there Is a slight disturbanceof balanceand proportionowing to the author's interest In amputationsthrough the foot which are discussed at some length. These, of course, have been discardedby most' surgeons becauseof equinus and other deformities. In this book an operationis describedwhich Is said to obviate thesedifficulties. There Is no mention made of klnresthetlc" amputationsof the forearm. Sometimes practical points are omitted, althoughthis Is unusualthroughoutthe book. In Figure 49, for example, most surgeonswould agree that a pad should have been placed betweenthe tourniquet and the arm even though a wide one was used. A word of warning on the use of tourniquetswould have beenapposite. The tourniquetas applied In Figure 62 Is even more dangerous. We cannot see the point of wrapping up the 11mb In 90% alcohol on the night precedingoperation; nor does it appear