130 SURGICAL ANATOMY OF 



surgical processes. In practice, the accurate knowledge 

 of the anatomy of the parts alone must guide the sur- 

 geon, as it is impossible to lay down rules for an ampu- 

 tation to meet the exigencies of every case. For rapidity 

 of execution, the former may be practiced, and it is based 

 upon the following anatomical considerations. It is de- 

 sired to direct the point of the knife in such a manner 

 that it may most readily and easily transfix the structures 

 above the joint (and in skilful hands the joint as well), 

 cut one flap, disarticulate, and expose a second flap, and 

 so leave all large arterial and venous trunks for division 

 until the last moment. The point to be felt for from the 

 surface, which serves as a guide for the point of the 

 knife to make for, is a spot between the acromion and 

 coracoid processes and below the coraco-acromial ligament. 

 Posteriorly, and below, the guide for the entry or emer- 

 gence of the knife, is the posterior margin of the axilla, 

 just in front of the tendons of the teres major and la- 

 tissimus dorsi; it is then pushed upward and forwards 

 the elbow being moved outwards and upwards, in 

 order that the head of the bone may be as low down in 

 the glenoid cavity as possible through the structures 

 close to the bone, until it emerges at the point above in- 

 dicated, and a large external flap cut; the joint is next 

 opened, and the attachments of the muscles around it 

 being divided, the elbow is carried in front of the chest, 

 and the head of the bone pushed backwards to put the 

 tendons on the stretch ; after the disarticulation is effect- 

 ed, a posterior flap of about the same length is to be 

 made, in which lie the vessels and nerves. 



Contents of Flaps after Disarticulation at Shoulder-joint 

 by Transfixion. The external flap thus fashioned will 

 contain, integument, the posterior fibres of the deltoid, 



