take his place outside the limb he is about to remove, while the assistant should stand at the shoulder of the subject. The arm being extended from the side, the assistant should encircle it just below the point at which it is to come off with both hands, and retract the integuments to their utmost. The operator bending both knees, should stoop down and pass his knife around the limb from its under side, and laying the heel of the blade on the side of the arm nearest to him, should make a circular sweep around the limb, at the same time straightening his own body, and rising to the erect position. This cut should divide the integuments down to the muscles, which must be bared of their covering to the extent of two or three inches, by dissecting off the skin and subcutaneous tissue; the assistant meantime turning back the parts while he retracts them. The muscles and all the remaining soft parts down to the bone should now be divided by a circular sweep of the knife, effected in the same manner as the incision of the integuments, the edge of the knife being laid close against the reflected integument. Let the assistant again grasp the muscles and integuments en masse, and retract them; the stump will now assume a conical form, and the operator should again sweep his knife around the bone; dividing this muscular cone about its centre, and applying the saw at the same spot, the operation will be complete.* The divided ends of the brachial, the superior and inferior profunda arteries, should be sought and recognised if possible, in the stump.

(b) In the amputation by double flaps the arm should be rotated outwards, the assistant and operator being placed as in the preceding method. Having with the left hand

* In sawing the bone, the operator should grasp it with his left hand just below the point of section; in this way only, will he effectually steady it.

grasped and raised the soft parts in front of the humerus, let the operator transfix them, the point of his knife grazing the anterior surface of the bone in its passage through the limb, and passing in front of the brachial vessels; a semilunar flap should be formed about three inches in length, as the knife cuts its way out. The operator should now grasp the soft parts on the posterior aspect of the limb, draw them away from the bone, and transfix them, cutting a posterior flap about the same size and shape as the anterior; sweeping the edge of the knife around the bone to clear it from any remaining connections, the saw should be applied as high up as possible, while the assistant retracts both flaps. The brachial artery should be looked for near the inner angle of junction between the anterior and posterior flap.

(c) To remove the upper arm by integumental flaps and by a circular division of the muscles, the operator should procure a short amputating knife, and should take his place outside the limb of the right side, inside that of the left, the arm being carried out from the side. Commencing on the side of the limb farthest from him, he should trace out in the skin and subcutaneous tissue a flap with its convexity downwards, and again, passing his hand under the limb, he should connect the opposite angles of the first incision by tracing a flap of the same size and shape on the posterior surface of the limb; these being retracted by the assistant, and reflected from their deep attachments to the fullest extent, the muscles should be divided at their base, as in the circular operation, and the bone sawn through as high up as possible.

For a description of Mr. Teale's method of amputating, we refer the reader to the general description of his plan of operating, at page 62, and to fig. 30, and fig. 31, page 107. In the upper arm the anterior flap should be made rather

external in position, and care should be taken to include the brachial vessels in the posterior or short flap.

Amputation of the arm at the shoulder-joint. — The plans adopted for disarticulating the humerus at this joint are very numerous, though many only differ from each other in inessential particulars. We shall only describe (a) the operation by an upper and a lower flap; and (b) that by an anterior and posterior flap.

(a) The body, being raised by two or three blocks placed beneath the shoulders, should be brought towards the edge of the table, the operator should stand outside the limb, and the assistant behind the shoulder. In this as in all operations for disarticulation at the shoulder-joint, an amputating knife of moderate dimensions will be found more commodious than the formidable weapon generally figured in books. The operator grasping the deltoid in his left hand, and raising it, should thrust his knife beneath it, transfixing the limb just below the acromion, and on its upper and outer aspect; the knife should graze the neck of the humerus, and in cutting its way out below should form a flap with a rounded border, about four inches in length; this the assistant raises and retracts. The head of the bone being now exposed, the heel of the knife should be laid on the upper aspect of the anatomical neck, and the muscles inserted into the greater tuberosity divided, while the bone is rotated inwards; the joint being opened on its upper and outer aspect, the subscapularis should be divided, the knife passed behind the neck of the bone, and with one sweep be made to cut its way out in the axilla, forming an inferior flap similar to the first. the living body the axillary artery should be controlled by pressure made against the first rib just external to the scalenus anticus; after the operation, its divided end will be found near the inner angle of junction between the

In

flaps. The preceding operation is modified by some surgeons, in that the anterior flap is cut and reflected, instead of being formed by transfixion.

(b) Disarticulation by anterior and posterior flaps. -The subject and assistant being placed as in the preceding operation, the operator, standing on the outside of the limb near the elbow, should grasp the shaft of the humerus low down, draw the arm out from the side, and at the same time throw the head of the bone forwards; he should insert the knife with its edge turned towards him, just in front of the

The arrow represents the direction in which the flap should be cut.

posterior fold of the axilla, and thrusting it upwards, close behind the neck of the humerus, should bring out its point as near the acromion as possible; the accompanying woodcut (fig. 19) shows the knife in its proper position, and the manner in which the humerus should be held. A flap should thus be cut from the posterior aspect of the limb, about four inches long, and oval at its extremity, this the assistant should grasp and keep it well retracted.

The

arm should now be thrown forwards across the chest (fig. 20), and the heel of the knife applied to the head of the bone to divide the three muscles of the greater tuberosity;

this will thoroughly open the joint on its posterior aspect, and will enable the operator to complete the division of the capsular ligament, to pass the knife from behind forwards, between the head of the bone and the glenoid cavity, and to divide the tendon of the subscapularis. Having now passed the knife round the head of the humerus, so that its blade rests against the front of the neck of the bone, the arm should be placed in the position shown in (fig. 21), and the operation completed by forming a flap-such as