THE SHOULDER-GIRDLE. 249 



Spence' s Method. A modification of Larrey's procedure, attributed to Spence 

 by the British and to S. Fleury by the French, consists in commencing the incision 

 just outside of the coracoid process in the interval between it and the acromion 

 process. This modification is probably the best form of procedure for this locality 

 and is the one which will be discussed here. It will be noticed, however, that it 

 practically changes the operation of Larrey from one with anteroposterior flaps to one 

 with a single external flap, as in the method of Dupuytren. (Fig. 263). 



The incision begins just below the coraco-acromial ligament and lies deep in the 

 hollow formed by the anterior concave surface of the outer third of the clavicle. It 

 divides the fibres of the deltoid muscle longitudinally a short distance from its anterior 

 edge. It will be recalled that the deltoid muscle covers the coracoid process and 

 extends just to its inner side to be attached to the outer third of the lower surface 

 of the clavicle. Between it and the adjoining edge of the pectoralis major muscle 

 runs the cephalic vein. This passes downward and outward along the inner edge 

 of the deltoid until it reaches the outer edge of the biceps muscle alongside of which 

 it passes down to the elbow. This vein will be cut as the inner branch of the 

 incision is made. The bicipital groove, when the palm of the hand faces forward, 

 lies almost directly below the coraco-acromial ligament. While the incision is being 

 made the arm is kept rotated slightly outward. 



As the knife descends it runs along the inner side of the bicipital groove and 

 divides the tendon of the pectoralis major muscle. As soon as this tendon is cut the 

 incision is inclined laterally. The incision having been carried down to the bone, 

 except on the inside of the arm, the deltoid flap is raised upward and backward. It 

 carries with it the circumflex nerve and posterior circumflex artery. 



The disarticulation of the bone is apt to be bungled unless one knows the con- 

 struction of the parts. It is to be borne in mind that the capsular ligament is to be 

 divided together with the tendons of the muscles inserted into the tuberosities. The 

 capsule does not pass across the anatomical neck to be inserted into the tuberosities 

 beyond, and the mistake is often made of cutting on the anatomical neck and there- 

 fore frequently the capsule still remains attached to the proximal side. The cut 

 may be commenced posteriorly and should be made on the head of the bone just 

 above the anatomical neck. The arm is to be adducted and rotated inward and the 

 muscles inserting into the greater tuberosity cut in their order, first the teres minor, 

 then the infraspinatus and supraspinatus with the joint capsule beneath them. Then 

 comes the long head of the biceps, and the arm now being rotated outward, the 

 tendon of the subscapularis is divided. In cutting the muscles and capsule across 

 the top of the joint, the arm is to be kept close to the side of the body so as to tilt 

 the upper portion of the capsule out beyond the acromion process. 



The head of the bone can now be drawn out sufficiently to allow the knife to be 

 introduced behind it to divide the inferior portion of the capsule. This should be 

 detached close to the bone so as to avoid wounding the axillary artery and especially 

 the posterior circumflex artery and the circumflex nerve, which wind around the 

 surgical neck immediately below and are to be pushed out of the way. 



The division is completed by cutting the remaining muscles passing from the 

 trunk to the shaft of the bone. On the inner side may be an uncut portion of the 

 pectoralis major, the coracobrachialis, and short head of the biceps ; below is the long 

 head of the triceps and on the outer side are the teres major and latissimus dorsi. 



On examining the face of the stump, posteriorly is seen the bulk of the deltoid 

 muscle with the triceps below, and then the latissimus dorsi and teres major tendons 

 lying next to the artery. Anteriorly is the cut edge of the deltoid and pectoralis 

 major with the coracobrachialis and short head of the biceps lying next to the artery. 



To the outer side of the artery lie the median and musculocutaneous nerves. 

 To the inner side are theulnar and lesser internal cutaneous nerves {cutaneus brachii 

 medialis} and the axillary vein. Posteriorly are the musculospiral and axillary 

 (circumflex) nerves. 



Sometimes the median nerve lies in front instead of to the outer side. The axillary 

 artery is divided below the origin of the anterior and posterior circumflex arteries. 

 The bleeding in the first cut will be from the cephalic vein (which runs between 

 the pectoralis major and deltoid), muscular branches of the posterior and anterior 



