Treatment. The general health of the patient is the first thing to be attended to; change of air, good diet, the different preparations of iron,

The patient should be kept out of doors as much as possible, and should be directed to take foot or horse exercise, but when not moving he should be required to lie down as much as possible, and not to sit upright. Mechanical support may be advisable in severe cases.

Angular Curvature, known as Pott's Curvature, is produced by softening and absorption of the intervertebral substances, and caries of the bodies of the vertebræ.

Symptoms. This disease usually begins with weakness, coldness and numbness of the legs, and incapability of making exertion; these symptoms are followed by twitchings and spasms of the legs, and sometimes palsy. In adults there is generally a dull, aching pain, aggravated by motion, and tenderness on pressure. If the patient slips when walking, he experiences great distress; this is one of the symptoms in children by which attention is called to their condition. If the disease is situated in the dorsal vertebræ there will be tightness of the chest and difficulty of breathing; if the cervical vertebræ are affected one or both arms may be palsied, and there will be difficulty in supporting the head. As the disease advances, the trunk becomes curved forward, and the spinous processes of the diseased vertebræ project backward. Abscesses may form; there is great constitutional derangement, with hectic.

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Treatment. Rest in the horizontal posture is absolutely necessary. bandage containing strips of whalebone, and reaching from the head to the hips, may be employed to keep the trunk at rest. Issues on each side of the spinous process of the diseased vertebræ may be used.

The constitutional treatment should be the same as that recommended for angular curvature, and for scrofulous cases generally.

Efficient mechanical support during convalescence is absolutely neces. sary; the plaster jacket of Dr. Sayre, of New York, is in general use, and the one most to be recommended.

AMPUTATIONS.

AMPUTATION AT THE HIP JOINT.

This operation is requisite in cases of cancerous or hopeless disease of the femur, and in those injuries in which the upper extremity of the thigh bone is smashed and the soft parts so much damaged that it is useless to attempt excision.

It is generally performed by flaps, either antero-posterior or lateral.. The femoral artery should be compressed and seized as soon as cut, by the hand of an assistant following the knife.

The arteries divided in this operation are the muscular and femoral, lying close together inside and in front of the bone.

The internal circumflex is also divided, and also the external circumflex. The great sciatic nerve and an accompanying branch of the ischiatic artery lie in the posterior flap, near its centre.

Operation by Antero-Posterior Flaps.-The thigh having been slightly bent and abducted, the knife is entered at the outside, at the junction of the upper and middle third of a line drawn from the anterior superior spine of the ilium to the great trochanter, and carried obliquely inward and downward immediately in front of and touching the joint, and finally brought out about two inches below the tuberosity of the ischium. A large anterior flap is made, about six or seven inches long, which is at once firmly grasped, to prevent hemorrhage, and drawn upward. The anterior part of the capsular ligament already laid bare is then divided, together with the cotyloid ligament; the head of the bone is dislocated by rotating the limb outward and extending it backward; the ligamentum teres cut through and the disarticulation completed. The knife is then carried through the joint, over the trochanter, and the posterior flap made somewhat small and thin. Sponges are stuffed into the wound by assistants, to restrain the hemorrhage, until the vessels are secured by ligatures; sutures, plasters and bandaging, complete the operation.

AMPUTATION OF THE THIGH.

Circular Method. The surgeon stands at the outer side. One assistant must hold the limb, and another must draw up the skin as high as possible. Then the surgeon, grasping firmly the knife, with the point upward and the edge toward his arm, commences by passing his arm under the limb, laying the edge of the knife over it, and makes a transverse incision at one sweep, completely around the limb, through the skin and fat, down to the fascia. The knife cuts from heel to point. The assistant now draws upon the skin and folds it back like a coat cuff; and then the knife, being put close to the edge of the retracted folded skin, is made to divide the superficial vessels, and then cut everything down to the bone by a clear sweep. Then separate the muscles upward from the bone, for an inch or two, with the point of a knife, and divide the periosteum. The soft parts are next to be drawn up from the bone by the retractor, and lastly, the bone is to be divided by the saw. Should the bone be splintered, the projecting parts must be removed by the bone forceps. The femoral artery must now be secured, its orifice being grasped and slightly drawn out by the

forceps; and afterward any large branches that appear in the muscular interstices. Then all compression should cease, so that arteries that are likely to bleed should do so. When the bleeding has finally ceased, the edges of the wound should be adapted with sutures, and a few long slips of plaster and a light bandage passed around the stump. The arteries divided are the femoral, the profunda, and the descending branches of the external circumflex.

Flap Operation.-The operator may stand on either side of the limb. In amputating the right thigh, he stands on the outer side and raises the flap with the left hand, and this gives him the power of grasping the main artery, with the flap, with that hand, and thus assisting in restraining hemorrhage. The flaps may be made from the inner and outer, or from

FIG. 61.

FLAP OPERATION.

the anterior and posterior aspects of the limb. He then passes his knife horizontally through it till its point touches the bone, over which he passes the point, pushes it through the other side of the limb as far back as possible. He then carries the knife along, close to the bone, for about three inches, and finally cuts out forward, so as to make the anterior flap spadelike, without corners. The knife is again entered a little below the top of the first incision, passed behind the bone, brought out at the wound on the other side, and cuts the posterior flap. Each of the flaps should be rather longer than the semi-diameter of the limb at the point operated on. Both flaps are now drawn back, the knife swept round the bone, to divide any remaining muscular fibres, and the bone sawn through.

AMPUTATION AT THE KNEE JOINT.

Long Posterior Flap.-(Syme's Operation.) A semicircular incision is made through the skin and fascia, over the patella; next the knife is thrust horizontally across, immediately behind the joint, and is made to cut a long flap from the calf of the leg; next, the anterior flap being lifted up, the extensor muscles are severed from the upper border of the patella; the remaining soft parts are divided, and the femur sawn through the condyles, immediately above the joint.

Long Anterior Flap Operation.—An anterior flap may be made, including the patella, by a semicircular incision through the tissues in front, below the patella, from the posterior part of one condyle of the femur to the other. Then the ligamentum patella is cut through, the patella lifted with the anterior flap; the joint opened by cutting through the lateral and crucial ligaments, and a posterior flap cut from the calf.

The inter-articular cartilages should be removed, and the surface of the patella and the femur, only if diseased. Some surgeons bring down the patella over the femur; others remove it.

The arteries divided are the anterior and posterior tibial, sural and

articular branches.

AMPUTATION OF THE LEG.

Double-flap Method, at the upper fourth of the leg. A stout bistoury, with blades four or five inches long, and a broad saw, are the cutting

instruments required. The flaps are made of integuments only, by cutting from the surface without transfixion. The point of the knife is entered at

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