400 ON AMPUTATION 



avoiding the site of the brachial vessels and nerves, is pushed on in front of the 

 bone ; and then, by sHghtly raising the handle, is made to emerge at a place 

 exactly opposite. The anterior flap is then cut with a brisk sawing movement 

 of the instrument, which is first directed longitudinally for a short distance, and 

 then turned gradually towards the surface, and brought out perpendicularly 

 to the integument. The flap is now hghtly raised by the assistant, without any 

 traction, for this would interfere with transfixion behind the bone, which is 

 effected through the extremities of the wound already made, and the posterior 

 flap is cut hke the anterior. The assistant now retracts the flaps firmly, when 

 a circular sweep of the knife exposes the bone about an inch above the angle 

 of union of the flaps, and another similar turn of the instrument prepares it for 

 the application of the saw. The edges of the wound meet accurately when 

 brought together, producing a symmetrically rounded stump. But when the 

 muscles are largely developed, it is well to avoid the inconvenience occasioned 

 by their redundancy, by cutting the flaps from without inwards, or by employing 

 the modified circular method. 



Amputation at the shoulder-joint is an operation which yields very satisfac- 

 tory results, as w^as strikingly shown by the experience of the late Baron Larrey, 

 who, during the wars of the first Napoleon, saved ninety out of a hundred cases, 

 in spite of the very unfavourable circumstances of military practice.^ 



Of the various methods that have been proposed, that of Lisfranc is the 

 most expeditious. The arm being raised so as to relax the deltoid, the point 

 of a long-bladed knife is introduced about midway between the coracoid and 

 acromion processes, and thrust round the outer side of the joint till it comes 

 out within the posterior fold of the axilla (or, if the left limb be the subject of 

 operation, the direction of transfixion is reversed), when a large muscular external 

 flap is rapidly cut ; and this being held up by an assistant, and the arm drawn 

 downwards and forwards, the joint is opened by cutting firmly upon the head 

 of the bone," which is then raised from its socket so that the knife may be passed 

 round it, and carried downwards along the inner surface of its neck and shaft, 

 followed by the other hand of the assistant, which grasps the tissues that lie 

 between the track of the instrument and the axilla, so as to prevent bleeding 

 from the main artery, when it is divided in the completion of the short 

 internal flap. 



This operation, however, is rarely available in practice. Its satisfactory 

 performance requires the leverage of the humerus, which is generally broken in 



^ Me'moire de Chirurgie tnilitaive, par le baron D. J. Larrey, tome iv, p. 434. 



^ Strictly speaking, this is Dupuytren's modification of the method of Lisfranc, who depressed 

 the arm at the commencement of the operation, and opened the joint during the transfixion ; but this 

 was a less easy proceeding, though shorter by a few seconds in very expert hands. 



