arrest bleeding during transportation, bandage the limb, sew the compress pad to a bandage, and place the plates of the instrument over the pad. Signorini's horseshoe tourniquet may be used upon the brachial artery. In hip-joint and shoulder-joint amputations Wyeth's pins are passed, and after the limb is emptied of blood the band is fastened above them. These pins prevent the bands from slipping.

The instruments and appliances required are Esmarch's apparatus or tourniquet, amputating-knives, a bone-knife, scalpels, saws, a lion-jawed forceps, bone-cutting forceps, a periosteum-elevator, retractors of linen, dissecting-, hemostatic, and toothed forceps, a tenaculum, an aneurysm-needle,

FIG. 310-Catlin, knife, and saws for amputations.

a probe, scissors, needles, ligatures, sutures of silkworm-gut, dressings, bandages, and solutions. A retractor has two tails for the thigh and arm and three tails for the leg and forearm it is made by taking a piece of muslin eight inches wide and twelve inches long and cutting tails on one side eight inches in length.

Methods of Amputating.-Circular Method (Fig. 311). The surgeon should stand to the right of the limb

FIG. 311.-Amputation of arm by the circular method (Druitt).

and use a long amputating-knife which cuts from heel to point. After an assistant has retracted the skin the operator divides the soft parts by a series of circular cuts. Do not cut at once to the bone, but divide the skin and subcutaneous tissues. At the retracted edge of the first cut divide the superficial muscles, and after these muscles retract divide the deep muscles. Incise the periosteum with a bone-knife, push up the periosteum with an elevator, and after the application of the retractors saw the bone, starting the saw from heel to point. A periosteal flap can be made to cover the end of the bone, but it is unnecessary. In this amputation is formed a

cone whose apex is the bone and whose base is the skinedge. In one form of circular amputation (amputation à la manchette) the retracted skin is cut by a circular sweep of the knife, a cuff of skin and subcutaneous tissue is freed and turned up, and the muscles are cut circularly at the edge of the turned-up cut (Fig. 312). The pure circular

FIG. 312.-Circular amputation: dissecting up the skin-flap (Esmarch).

amputation is performed on the arm and the thigh; the amputation à la manchette is performed chiefly through the wrist and the lower forearm.

Modified Circular Method. In this operation the circular skin-cut may be modified by making a vertical incision to join the first wound, the muscles being cut by a circular sweep or by making two vertical skin-incisions. Liston's modification consists in dissecting up two short semilunar integumentary flaps and in dividing the muscles circularly. This is known as the "mixed method" (Fig. 313). The

FIG. 313.-Modified circular amputation: skin-flaps and circular through muscles (Esmarch).

modified circular can be used upon the thigh, the leg, the arm, and the forearm.

Elliptical Method. This method stands midway between the circular operation and the operation by a single flap. An elliptical incision is made through the skin and subcutaneous tissues, the tissues are pushed up or turned back, and the muscles are divided circularly or cut partly by transfixion. This method is employed particularly in certain disarticulations.

Oval or Racket Method.-In an oval amputation the incision through the skin and subcutaneous tissue is an oval with a pointed end or a triangle, and the other parts down to the bone are cut from without inward. When a longitudinal incision down to the bone (Fig. 318, a, b) extends from the point of the oval (a, b) the operation is called the "racket" amputation. If the longitudinal cut joins a circular cut, the operation is known as a "T" amputation. The oval or racket operation is performed at the metacarpophalangeal, metatarsophalangeal, and shoulder-joints; the T operation may be performed at the hipjoint.

Flap Method. A flap may be composed of skin only or of both skin and muscle, but the skin-flap must always be longer than the muscle-flap, so that the latter will be covered

FIG. 314.-Amputation of the thigh by transfixion (Gross).

by it. A flap containing much muscle heals badly, but the best flap has a moderate amount of muscle (enough skin to cover the muscle and enough muscle to cover the bone). Flaps may be single or double. Double flaps may be lateral or anteroposterior, square or U-shaped, equal or unequal, and they may be cut by transfixion (Fig. 314), by cutting from without inward, by dissection, or by cutting the skin from without inward and the muscles by transfixion. When an amputation is completed, tie the main vessels, pull down the nerves and cut them high up, smooth the flaps, take off the constricting band, and after arresting hemorrhage apply sutures. In some cases the deep parts are stitched with a continuous catgut suture and the superficial parts are closed with silkworm-gut; in other cases the deep parts are not stitched at all, the skin alone being sutured with silkworm-gut. Drainage-tubes should be used except in amputations of the fingers and toes.

SPECIAL AMPUTATIONS.

Fingers and Hand.-In amputating the thumb and index finger save every possible scrap of tissue. In either of the fingers, if it be necessary to amputate above the middle of the middle phalanx, the attachment of the flexor tendons will be cut off and the finger will be liable to project directly backward, so that it is better with these fingers either to disarticulate at the metacarpal joints or to stitch the flexor tendons to the periosteum. The flexor tendons have fibrous sheaths extending from the proximal end of the distal phalanx to the metacarpophalangeal articulations, these sheaths being thin and collapsible opposite the joints, but being thick and rigid opposite the shafts of the bone. The fibrous sheath is known as the theca, and when it is cut in an amputation it should be closed, otherwise it may carry infection to the palm of the hand. The theca does not exist over the distal phalanx, and it is not distinctly visible over the joint between the distal and middle phalanges. To effect closure over the shaft of a bone, strip up the periosteum and pass catgut sutures vertically through the theca and the periosteum (Treves). In amputation of the fingers and the thumb an Esmarch bandage is unnecessary, though pressure may be made upon the arteries at the wrist. Only two or three ligatures are necessary. Close with a very few sutures, so as to favor drainage between the threads.

A

B

D

E

FIG. 315-Amputation of the finger.

The distal phalanx is best removed by a long palmar flap (Fig. 315, A). The palmar flap (A) is marked out by cutting through the skin and subcutaneous tissue. The incisions are next carried to the bone, the flap is dissected from the bone, the finger is strongly flexed, a transverse incision (B) is carried across the dorsum on a level with the base of the third phalanx, the soft parts are pushed back, the joint is opened, the lateral ligaments are cut from within outward, the third phalanx is forcibly extended, and the remaining structures are cut from below upward. The middle phalanx can be removed by the same method (c). The proximal phalanx can be removed by a long palmar flap or by a long palmar and a short dorsal flap (D, E).

Disarticulation of a metacarpophalangeal joint is best performed by the oval or racket method. The incision upon the dorsum (A) is begun just above the head of the metacarpal bone, is carried down to beyond the base of the

phalanx, and involves the skin only (Fig. 316). One incision sweeps around the finger at the level of the web, going only through the skin (B); the finger is extended and the palmar cut is carried to the bone; each lateral incision is carried to

FIG. 316. A, disarticulation of a metacarpophalangeal joint; c, amputation of a finger with the metacarpal bone.

the bone while the finger is bent in the opposite direction, the flaps are dissected back to the joint, the finger is strongly extended, the joint is opened from the palmar side, and disarticulation is effected. Cutting off the head of the metacarpal bone improves the appearance of the stump but weakens the hand, hence in a workingman it must not be done unnecessarily. If it is necessary to remove a metacarpal bone, the incision (c) is made from the carpometacarpal joint.

Amputation of the thumb through its distal or proximal phalanx is performed identically as is an amputation of a finger. Amputation of the thumb, with a portion or the whole of its metacarpal bone, is performed by the oval or racket incision. Amputation of the wrist-joint can be done by the circular method or by a double flap. In the double-flap amputation a dorsal flap is made by carrying a semilunar skin-incision between the styloid processes; the skin is lifted, the wrist is forcibly flexed, the joint is opened by a transverse cut, and a long semilunar palmar flap which includes only the skin and fascia is made by dissection.

Amputation through the forearm may be effected by the circular method (Fig. 312), the modified circular,

FIG. 317.-Modified circular amputation of the forearm (Bryant).

or the flap operation. An excellent plan is to make a semilunar dorsal skin-flap and a semilunar skin-flap on the flexor surface. The flaps are raised, the muscles are cut circularly (Fig. 317), the interosseous space is cleared with the knife, a three-tailed retractor is applied, the periosteum is pushed up, and the bones are sawn half an inch above the flap. In sawing the bones, start the saw upon the radius, draw it from heel to point, make a furrow on the radius and ulna, and saw both bones at same time. After sawing, cut away any irregular edge with bone-pliers. In the lower third Teale's amputation may be done, the dorsal flap being the long one. In Teale's amputation rectangular flaps are made. The long flap is equal in width and length