of the joint, to such an extent as to admit of the shattered fragments being removed, either by the forefinger or strong forceps. When the operation is for disease, the head of the bone can be turned out of its socket, by a slight twist of the arm below. The arm should be held steady, and as much as is deemed necessary should be removed by the saw. The injured or diseased portions having been taken away, the glenoid cavity should be carefully examined, as also the acromion and the diseased parts scooped out with gouge or cut off with pliers. The principal vessel requiring ligature is the posterior circumflex. The flap should now be let down and the edges stretched, and the arm retained in a sling. Afterwards the joint becomes stiff, or partially anchylosed; still, there is such free play of the clavicle and scapula, and also of the articulations below, that a useful and even ornamental extremity remains, instead of a mutilated trunk.

The surgeon should not limit himself to one mode of procedure, but trust to his anatomical knowledge and operative skill, and adapt his measures to the peculiarities of the case. Flaps may be made of any form, and the surgeon has the option of cutting in any direction where there is no fear of coming in contact with any large vessel or nerve.

Only one case of resection of this joint was admitted from India; but there is another case where a secondary operation was performed at Fort Pitt, in a patient who is returned as a wound of the joint.

In the Crimean war the head of the humerus was removed twice as a primary operation during the first period of the war, or that ending March, 1855, and eight times during the second. One of the two first mentioned ended in death, and of the eight subsequent operations only one proved fatal.

"The head of the bone was five times removed as a secondary operation, without a single casualty, all the cases except one making good and comparatively rapid recoveries. In addi tion to these, there was a case in which the head of the bone and a large portion of the scapula, broken into fragments, were removed."

"Out of the total number, then, of 16 cases, 3 deaths took place, or 18.9 per cent. Had this operation not been resorted

to, amputation at the shoulder-joint, it is believed, would have become necessary in all."

Nineteen cases of resection occurred during the Schleswig Holstein war. Of these, 7 died, and 12 recovered with useful and movable articulations. Of the 7 fatal cases, 2 were primary operations, 2 were performed during the reaction stage, and 3 were secondary resections.

This mortality at first sight appears rather high; but the conditions under which they were performed must be taken into consideration: they were done, as Esmarch states, under circumstances in which more than a third of all amputations of the arm died. They died of pyæmia. Stromeyer and Esmarch both agree that the most favorable time for resection is either within the first twenty-four hours, or when suppuration is fully established.

Abscesses and sinuses are apt to form in the vicinity of the joint, and occasionally cause considerable trouble. A good deal of this depends upon the form of incision selected, so as to allow of the free discharge of pus. Bandens, who has had great experience, recommends the straight incision, so as to avoid cutting the fibres of the deltoid, and it is also necessary to save the long tendon of the biceps, if possible.

Stromeyer advocates the semicircular incision over the posterior surface of the joint, which certainly allows of the free exit of pus; but to cut across the fibres of the deltoid must in some degree impair the limb, although Esmarch states that to cut across the fibres of the deltoid does not much interfere with its after usefulness. Even in those cases where the single incision has been employed, the patient frequently has very little or no power of raising the arm from the side, as was exemplified in the case of Private James M'Donald, 79th Regiment, from the war in India, and others that have come under notice here.

As there are generally two apertures, the surgeon may wish to include them in his incision; but each method will possibly be found to suit in different cases. It is seldom necessary to take away more than the head and a portion of the shaftperhaps nearly as low as the insertion of the deltoid; but in the Schleswig Holstein war it is shown that as much as four

inches and a half were removed from the humerus, and yet a most useful arm remained.

Esmarch makes the following observation:-" It is curious that the operation on the left side seems to give less favorable results than on the right. 6 of 12 died of those resected on the left; 1 out of 7 of those resected in the shoulder on the right side. A similar proportion held good in resections of the elbow, in whom, of those operated upon on the left, 4 in 19, on the right 2 in 20 resections proved fatal. From this, the fatality attending operations on the left arm to that on the right is as 3 to 1; but of course further observations are required to enable conclusions to be deduced."

The following is a primary case of excision of the head of the humerus by one straight incision from India:-Private James M'Donald, 79th Highlanders, wounded at Lucknow, March 11th, 1858, by a musket ball, which struck him in the left shoulder, splintering the head and shaft of the humerus to a considerable extent. The ball then passed backwards and downwards, injuring the lower angle of the scapula, and lodged between that bone and the ribs, from which position it was extracted. The shattered parts of the head of the humerus and part of the shaft were excised the same day, by one long incision through the anterior part of the deltoid muscle. September 26, 1858.-There is a large cicatrix in front of the shoulder-joint, and a sinus in its centre, leading down to diseased bone. He cannot raise the arm from the side, on account of loss of power over the deltoid. He has been sent to modified duty, December 22nd, 1858.

The two following cases of secondary operations are good examples of perforating gunshot wounds through the head of the humerus, followed by anchylosis of the joint, and the track of the ball remaining carious, necessitating resection of the head of the bone:

93rd Regiment.-Private John Frazer, æt. 33, seventeen years' service. Was wounded at Lucknow, March 14th, 1858, by a musket ball, which entered the left shoulder beneath the acromion, and passed backwards, apparently through the humerus close to its head. March 2nd, 1859.-There is now anchylosis of the shoulder-joint. Much dead bone in frag

ments can be felt both from the anterior and posterior openings. General health good. 17th.-The head of the humerus was excised, and it shows the track of the ball to be in a carious state. Numerous smaller pieces were also taken away by the gouge.-Invalided.

9th Regiment.-Private John Morgan, æt. 39. Eighteen years' service-ten of them in India. Was wounded in action at Idaliff, in September, 1842, the ball passing through the right shoulder-joint and injuring the scapula. On admission into Fort Pitt Hospital, June 9th, 1844, there were three sinuses, two on the anterior aspect of the joint, one opposite the coracoid process, where the ball entered, and the other at the lower border of the axilla, and another on the posterior aspect, the exit of the ball, each communicating with diseased bone. Excision was performed on June 22nd, 1841, by me; a semilunar flap was made of the deltoid, embracing the entrance and exit of the ball; and on attempting to dislocate the humerus, this was found impossible, on account of complete anchylosis of the joint. The humerus was sawn across about two inches below its head, then cleared of soft parts, and raised; its attachment to the glenoid cavity was broken down by means of cutting pliers. The wound healed quickly, and he gradually regained the powers of motion in the arm. No. 2919. Head and neck of the right humerus, which was excised on account of caries consequent on a gunshot wound. The large, deep groove is the track of the ball; it is carious a little below the groove. There is an aperture, about one fourth of an inch in diameter, situated on the inner aspect of the bone, leading into the medullary cavity. The tubercles and upper part of the shaft are enlarged from depositions of new osseous

matter.

Excision in any part of the shaft of the humerus is seldom required, but should it be necessary, there can be neither difficulty or danger in doing so by making an incision on the outer or posterior surface of the arm.

RESECTION OF THE SHAFT OF THE HUMERUS.

The following preparation, where three quarters of an inch of the shaft of the humerus were resected in a case of comminuted fracture eight months after the injury. Death from pyæmia one month after the operation:-No. 2920. Humerus exhibiting a gunshot fracture below its centre. The end of the lower portion is healthy. There is a superficial exfoliation of a large portion of the outer layer of the shaft of the superior fragment, and also of the medullary canal.-Donor, C. Reade, Staff Surgeon, 95th Regiment. -Private Thomas, æt. 22 years, when on duty in the trenches before Sebastopol, was struck by a fragment of shell on the left arm, producing a compound comminuted fracture of the humerus, an inch below its centre, August 18th, 1855. On admission into Brompton Hospital, February 18th, 1856, the wound had healed, but re-opened on April 18th. At this time firm ligamentous union had taken place between the ends of the fractured bone, and a false joint had been established. On April 22nd he was in an excellent state of health. It was determined to perform the usual operation for effecting union of the shaft of the bone. A free and deep incision was made in the outer aspect of the left arm, about an inch below the insertion of the deltoid muscle, and carrying it perpendicularly downwards to a level with the condyles, dividing, amongst other muscles, the outer belly of the triceps. Owing to the obliquity of the fracture, and the strength of the ligamentous structure holding the bones together, some difficulty was experienced in passing the knife through the ends of the bones. After further dissection, threequarters of an inch were sawn off with a metacarpal saw from the fractured ends. There was but little blood lost during the operation, though several ligatures had to be applied. The patient was under the influence of chloroform. Some considerable time after, he was removed to his ward, and reaction had taken place; profuse hæmorrhage occurred from the wound, probably from deeply-seated muscular branches, but was stopped eventually by the application of ice. The limb was placed in a gutta-percha splint. On the evening of the following day the