AMPUTATION OF THE THIGH.

I should strongly recommend the surgeon who is not in the frequent habit of performing this operation, and who does not regard brilliancy of operation beyond its real value, to measure the limb, and to trace out the lines of his intended incisions with ink, either before the patient is removed from his bed, or when he is placed on the operating-table. By this precaution he may guard against making the long flap of too small dimensions.

Supposing the amputation to take place at the lower part of the middle third of the thigh, a situation well suited for the adaptation of an artificial leg, the circumference of the limb is to be measured at the point where the bone is to be divided. Assuming this to be sixteen inches, the long flap is to have its length and breadth each equal to half the circumference, namely, eight inches. Two longitudinal lines of this extent are then traced on the limb, and are met at their lower points by a transverse line of the same length. The inner longitudinal line should be first traced in ink as near as practicable to the femoral vessels, without including them within the range of the long flap. The outer longitudinal line, which is somewhat posterior, is next marked, eight inches distant from the former, and parallel to it. These two lines are then joined by a

transverse line of the same extent, which falls upon the upper border of the patella, or upon some lower portion of this bone. The short flap is indicated by a transverse line passing behind the thigh, the length of this flap being one fourth that of the long one; or, assuming the circumference of the limb to be sixteen inches, and the length of the long flap eight inches, the length of the short flap is two inches.

The operator begins by making the two lateral incisions of the long flap through the integuments only. The transverse incision of this flap, supposing it to run along the upper edge of the patella, is made by a free sweep of the knife through the skin and tendinous structures down to the femur. Should the lower transverse line of the flap fall across the middle or lower part of the patella, the transverse incision can extend through the skin only, which must be dissected up as far as the

upper border of the patella, at which place the tendinous structures are to be cut direct to the thigh-bone. The flap is completed by cutting the fleshy structures from below upwards close to the bone. The posterior short flap, containing the large vessels and nerves, is made by one sweep of the knife down to the bone, the soft parts being afterwards separated from the bone close to the periosteum, as far upwards as the intended place of sawing.

The arteries being secured, the flaps may be united by suture immediately; or they may be lightly placed in apposition, the stump being wrapped in a fold of napkin for four or six hours, when any clotted blood may be gently removed by a sponge, and the flaps finally adjusted. I prefer the latter method, as we thereby avoid the evil of infiltration of the tissues of the stump with blood, which often is the cause of suppuration in these parts.

In adjusting the flaps, the long one is folded over the end of the bone, and brought, by its transverse line, into union with the short flap, the two corresponding free angles of each being first united by suture. One or two additional stitches complete the transverse line of union. Care is now required in arranging the two lateral lines of union. As the long flap is folded upon itself so as to form a kind of pouch for the end of the bone, it is requisite that it should be held in its folded state by a point of suture on each side. Another stitch on each side secures the lateral line of the short flap to the corresponding part of the long one. A longitudinal line of union thus passes at right angles each end of the transverse line. The position of the longitudinal line at each end of the transverse one, will be rendered more easily intelligible by reference to the accompanying diagram.

FIG. 3.

In this diagram the length of the long flap is somewhat exaggerated.

The flaps being thus arranged, the stump is placed,

as described at a former page, without any dressing, on a pillow, over which a large sheet of gutta percha tissue has been spread. A light linen cloth is laid loosely over the stump and pillow, which are protected from the pressure of the bed-clothes by a wire-guard, or any other convenient apparatus.

The after-treatment is to be conducted as already described.1

The accompanying engraving, from a photograph taken in June, 1858, represents the stump of John Whiteley, eleven months after amputation, and five months after he began to wear an artificial limb. He now walks many miles a day, bearing two thirds of his weight on the end of the stump.

FIG. 4.

It is interesting to observe in this, as in other cases,

the extent to which the retraction of the short flap, con