septic absorption, than the operative procedure. The method of procedure should be selected with especial reference to the avoidance of these serious mishaps. Various excellent instruments have already been mentioned in another part of this work, and when these are skilfully employed during the performance of this operation, the quantity of blood lost will not seriously endanger the life of any patient, and a strict adherence to Prof. Lister's antiseptic method of treatment obviates the danger arising from septic complications; and furthermore since it limits suppuration to the minimum, and always aims at securing union by first intention it will certainly greatly diminish the frequency of secondary hemorrhage.

FLAP AMPUTATION AT THE COXO-FEMORAL ARTICULATION.

This operation may be performed by either antero-posterior or lateral flaps; and those commonly employed are properly designated as the musculo-cutaneous; although some surgeons. prefer that they should be composed chiefly of integument and cellular tissue. The formidable character of this operation renders it incumbent on the surgeon, prior to commencing this operative procedure that he provide carefully for all the details of the same, and also be prepared to meet any emergency which may arise. The operator ought therefore as a preliminary step to select at least three well-trained surgical assistants, and also a competent physician to administer the anesthetic.

It is highly important that the physician having charge of the administration of the anesthetic should possess the confidence of the operator to such a degree, that the latter may entirely withdraw his attention from this part of the operation, and concentrate his thoughts on that which is more immediately connected with the removal of the limb. The patient having been fully anæsthetized may then be placed in that position on the operating table, which enables the operator to accomplish the operation most readily. It is generally conceded that this is best accomplished when the patient is so placed that the pelvis on the diseased or injured side projects over the lower

border of the table, the leg at the same time being flexed on the thigh, and the thigh slightly flexed on the body, the whole limb moderately abducted, and the scrotum drawn toward the healthy side. The position and duties of the surgical assistants should be as follows: No. I should take charge of the abdominal tourniquet, and may stand on either side of the patient, while the instrument should be applied to the abdominal aorta a little below and to the left of the umbilicus. No. 2 should stand on the opposite side to the operator and be prepared to grasp the anterior flap and compress the femoral vessels. No. 3 should grasp the limb firmly, and be prepared to move it as required during the operation. All things now being in readiness, the operator assumes that Fig. 126.

position which enables him to perform this particular operation with the greatest facility, a position which must depend on the limb which he is about to remove, as well as other circumstances, and he now feels for the tuber-ischii and the anterior superior spine of the ilium, which are the anatomical guides in this operation. The blade of the amputating knife should be at least twelve inches in length, and its point should be lateral, and the anterior flap cut in different ways according to the side of the body on which the operation is made. If it be on the left side, the knife should be entered as shown in Fig. 126,

i. e., about two inches below the anterior superior spine of the ilium, or midway between it and the trochanter major; the knife is now carried directly across the joint on a line parallel with Poupart's ligament, and at the proper depth to insure the opening of the joint capsule, and finally it is brought out on

the inner side of the limb at the juncture of the thigh with the scrotum. In the performance of this part of the operation the surgeon should carefully avoid wounding the scrotum or the opposite thigh; the back of the knife must run parallel to, but not against the pelvis, and the point must not be held too high, lest it enter the obturator foramen. The knife is now carried quickly downward and outward by a sawing motion, thus forming an anterior flap of the proper length and shape, which is instantly seized and drawn backward by the assistant, who at the same moment so compresses the vessels between his fingers as to completely arrest all hemorrhage. The appearance of the parts at this stage of the operation is well shown in Fig. 127.

wound formed by the anterior flap, after which this knife is drawn through a semicircular line which intersects the same wound at its upper and outer angle; this incision is then carried down to the bone, thus forming a posterior flap of the proper size and shape. The dimensions of this flap must be proportioned to the diameter of the limb and the length of its anterior fellow. The flaps having been completed, the next step in the operation consists in disarticulating the hip-joint, which may be quickly accomplished by first passing the knife around the joint, then dividing the capsular and other ligaments, while the flaps are well drawn up by an assistant. Fig. 128 represents the formation of the posterior flap by cutting from within outward and downward.

carry it backward while the surgeon is opening the capsule and cutting the posterior flap. This operation having been properly performed, the surgeon being careful to preserve a long anterior and a short posterior flap, there will be no reason to find fault

with the facilities given for the proper drainage of the wound. The appearance of the stump after the closure of the flaps is well shown in Fig. 129.

AMPUTATION AT THE HIP-JOINT BY A CIRCULAR AND VERTICAL INCISION.

The soft parts are quickly divided down to the bone about five inches below the superior border of the trochanter major by a single powerful sweep of the knife, and all the bleeding vessels, veins as well as arteries, are immediately ligated with catgut. If the operator for any reason anticipates trouble from hemorrhage during the performance of the operation, it would then be advisable, prior to making the circular incision, to cut down on the femoral vessels in Scarpa's space and ligate both the artery and vein, or otherwise control the flow of blood through them by the aid of suitable forceps above and below the point at which