night, the 19th of February. About ten minutes previous to his admission, whilst driving very rapidly, he attempted to get off the car, and in so doing, while his foot was on the step of the vehicle, the step broke, and the foot passed back, getting between the spokes of the rapidly revolving wheel. The result of this unfortunate accident was, that he sustained an extensive compound comminuted fracture of both bones of the leg. The fibula was fractured in three places, and the tibia, which was broken at about the junction of the middle and lower thirds, was projecting through the soft parts at the inner side of the leg. There was extensive contusion and laceration of the soft parts, which extended as high on the outside of the leg as the head of the fibula. Looking at the numerous fractures that were present, and the great amount of laceration and exposure of the soft tissues, any attempt at saving the limb was obviously hopeless; and also having regard to the fact that the laceration. and contusion of the soft parts extended as high as the head of the fibula, I deemed an amputation of the leg at the "place of election" impracticable. I considered, therefore, that, under these circumstances, the supra-condyloid amputation would be the most suitable, and accordingly performed it precisely in the manner I have described in the preceding case. There was in this case, as there generally has been in the primary amputations I have performed, secondary hæmorrhage. It occurred twice. The first time was about half an hour after the operation, and the second on the third day. The first time I was obliged to undo the sutures, and seek for the bleeding vessels, which, I may mention, had in the first instance been apparently effectually secured by torsion. The second time the application of Signoroni's tourniquet for half an hour on the femoral artery had the effect of successfully arresting the bleeding. After this the case progressed most favorably, and, as in the first case, the result was perfectly good.

I may now indicate what I believe to be the advantages of the supra-condyloid amputation over, first, the amputations through the knee-joint with preservation of the patella, those,

namely, of Velpeau, Lane, Blenkins, and Markoe; secondly, the amputation through the condyles, as practised by Syme, Sir W. Ferguson, and others, operations which are closely analogous to, if not identical with, the original operation of Hoin; thirdly, Mr. Carden's operation, and its modification by Gritti; and lastly, the other amputations of the thigh, in which the medullary canal is necessarily opened.

Many of the advantages of this operation are doubtless common to it, and to the amputations suggested originally by Hoin and Velpeau; for instance, the stumps being more useful for progression in consequence of the possibility of making pressure on its extremity, and the patient not being obliged to walk as if he had anchylosis of the hip-joint, as is always the case when the point of support is at the pelvis instead of at the extremity of the stump. The diminished liability to tubular sequestra is another advantage common to all the amputations at the knee-joint. Again, the operation being further removed from the trunk, makes it less hazardous to the patient. The shock is less than in the amputations higher in the thigh, as the muscles which are divided are few in number, and these are divided, not through their thick fleshy bellies, but at their tendinous extremities. The muscular interspaces, in which suppurative inflammation so often occurs after ordinary amputations, not being opened, the chances of this occurring are at all events diminished-a point which Dr. Markoe strongly dwells on. There is less liability also to suppuration, from the fact that the parts divided in making the anterior flap are only skin and fasciæ. In connection with the diminished liability to suppuration, I would also mention here the fact that the posterior surface of the anterior flap in the supracondyloid amputation is covered with a natural synovial lining.

In Carden's and all other flap amputations in this situation, the posterior surface of this flap contains the obliquely divided open mouths of innumerable arteries, veins, and lymphatics, and large numbers of which have also fenestrated openings in them as well. This peculiarity of

the supra-condyloid amputation must, I am convinced, largely diminish the chances, not only of subsequent exhaustive suppuration, but also of purulent absorption. There is another feature in this operation which I believe must lessen the probability of the pyæmia. Professor Langenbeck has suggested that in amputations of the thigh the cut surface of the bone should, in order to prevent its divided vessels coming in contact with the suppuration in the wound, be covered by a periosteal curtain which, previous to dividing the bone, should be taken from the anterior surface of the femur, commencing about an inch below the point of section. As regards the value of this suggestion for diminishing the mortality of thigh amputations, having only tried it in a very 'few cases, I am not yet in a position to either verify or disprove Professor Langenbeck's statement on this point. I have, however, tested this plan as well on the human subject as on the lower animals, and the results of my experiments would tend to show the great liability of the periosteal curtain to slough away, and not become adherent to the cut surface of the bone. In the supra-condyloid amputation, however, we have an osseous curtain covering the cut surface of the femur which never yet has been known to slough away, so that if there be any value in Professor Langenbeck's suggestion the supra-condyloid amputation must have this among its other advantages. The preservation of the portion of the patella, to which the tendon of this powerful extensor of the thigh is attached, has, however, other obvious advantages. These are the increased power of extending the thigh in progression, and rendering the formation of a conical stump impossible. If the section of the patella be not made these advantages do not exist. In the first place because the elevated ridge dividing the posterior surface of the bone into two unequal portions effectually prevents the divided surface of the femur and patella being in perfect contact. Again, unless osseous anchylosis takes place, there can be no standpoint or firm point of fixation for the extensors to work on; and, lastly, there will always be liability to exfoliation or necrosis of the cartilage of the patella.

Lastly, there is an advantage in the supra-condyloid operation which is possessed by the ordinary circular method of amputation, and which, among other reasons, makes so many surgeons, myself among the number, in amputations of the arm and thigh cling to the circular method in preference to the ordinary flap operations, and that advantage is that the vessels are divided at right angles to their continuity, and not obliquely as they are in all flap operations, which must render these vessels more liable to take on inflammatory action from the wounds in them being necessarily so much greater in extent. I think, therefore, I may fairly claim for the operation which has been the subject of this communication, among other advantages that I have already mentioned, those of both the circular and flap amputations and the defects of neither.

DESCRIPTION OF PLATE III.

Michael Crow, æt. 32, tailor. Case of supra-condyloid amputation of the thigh for extensive carious disease of the bones of the left leg, ankle-joint, and metatarsus.