Syme's amputation for gangrene from peripheral vascular disease.

Peripheral vascular disease as a cause of amputation was first forcefully brought out in Canada by the many cases of acute thromboangiitis obliterans occurring in young men after World War I. In the early days of the 20's, amputation for this disorder was carried out at knee level (Gritti-Stokes), an operation itself considered a daring innovation at the time, the site of election in such cases then being viewed as the junction of the upper and middle thirds of the thigh. In the present series, the first Syme amputation for gangrene of the foot was performed in 1925 in a case of thromboangiitis obliterans. Since that time, the Syme amputation has been used in Canada in such cases whenever it seemed warranted. By 1940, Syme's amputation had been used successfully for many and varied conditions, including infected and perforating ulcers in unrecovered sciatic-nerve and cauda-equina lesions, septic and tuberculous arthritis of the ankle joint, frostbite, arterial occlusion, and gangrene owing to peripheral arterial disease. When, after the beginning of World War I I , the question of amputations once again became prominent, we were able to refute the views expressed by the British Ministry of Pensions in regard to Syme's and other end-bearing amputations generally. We showed, by demonstration of actual cases, the great value and durability of these amputations in active life. We were fortunate in having an excellent prosthetic service started during World War I and concentrated in February 1919 at the Dominion Orthopaedic Hospital (later Christie Street Hospital). It had constantly been improving our prostheses, and to that group we owe much of our success. During the period 1920-1956, many new factors modified our views and methods of treatment. In 1930, lumbar ganglionectomy was adopted in vascular disease, and it is thought that doing so saved or postponed many major amputations. Embolectomy and anticoagulants saved some limbs. Sulfa drugs, penicillin, and later antibiotics bolstered our courage. Although the incidence of infection was no lower after than before the use of such agents, there were operated upon during World War II cases that in World War I would not even have been considered for surgery. Now arterial grafting promises well in selected cases. Advances in anesthesia and in medicine generally have of course helped a great deal. Of the problems facing the Department of Veterans Affairs today, one is senile gangrene owing to the advancing age of veterans.